Provider Demographics
NPI:1801060660
Name:KELLY M. GONZALES, DDS, PC
Entity type:Organization
Organization Name:KELLY M. GONZALES, DDS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-864-9595
Mailing Address - Street 1:1103 RIVERY BLVD
Mailing Address - Street 2:STE 140
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-3034
Mailing Address - Country:US
Mailing Address - Phone:512-864-9595
Mailing Address - Fax:
Practice Address - Street 1:1103 RIVERY BLVD
Practice Address - Street 2:STE 140
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-3034
Practice Address - Country:US
Practice Address - Phone:512-864-9595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty