Provider Demographics
NPI:1831852623
Name:IRIZARRY GONZALEZ, ASHLEY NICOLE (DMD)
Entity type:Individual
Prefix:DR
First Name:ASHLEY
Middle Name:NICOLE
Last Name:IRIZARRY GONZALEZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CALLE ALCALA APT 503
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00921-3937
Mailing Address - Country:US
Mailing Address - Phone:787-514-2652
Mailing Address - Fax:
Practice Address - Street 1:4014 14TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:00956
Practice Address - Country:US
Practice Address - Phone:941-708-6504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-19
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL27812122300000X, 1223X2210X, 1223G0001X
PR003431122300000X, 1223G0001X, 1223X2210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No1223X2210XDental ProvidersDentistOrofacial Pain
Provider Identifiers
StateIdentifier IDID TypeIssuer
403153972OtherSTUDENT ID