Provider Demographics
NPI:1841372471
Name:GONZALES, EDWARD D (DDS)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:D
Last Name:GONZALES
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 1:1406 15TH ST N
Mailing Address - Street 2:
Mailing Address - City:WAHPETON
Mailing Address - State:ND
Mailing Address - Zip Code:58075-3519
Mailing Address - Country:US
Mailing Address - Phone:701-642-8121
Mailing Address - Fax:
Practice Address - Street 1:100 LAKE TRAVERSE DR
Practice Address - Street 2:
Practice Address - City:SISSETON
Practice Address - State:SD
Practice Address - Zip Code:57262-0189
Practice Address - Country:US
Practice Address - Phone:605-742-3678
Practice Address - Fax:605-742-3887
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0337701223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health