Provider Demographics
NPI:1831245059
Name:GONZALEZ, OTTO (DDS)
Entity type:Individual
Prefix:
First Name:OTTO
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 METROPOLITAN OVAL
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-6630
Mailing Address - Country:US
Mailing Address - Phone:718-239-7200
Mailing Address - Fax:718-794-5860
Practice Address - Street 1:64 METROPOLITAN OVAL
Practice Address - Street 2:SUITE 2
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-6630
Practice Address - Country:US
Practice Address - Phone:718-239-7200
Practice Address - Fax:718-794-5860
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037159122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00762574Medicaid