Provider Demographics
NPI:1790477818
Name:GONZALEZ, ANN PRECILLA
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:PRECILLA
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7821 AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90003-2358
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:711 W FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-6105
Practice Address - Country:US
Practice Address - Phone:323-789-5610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-25
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1107651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program