Provider Demographics
NPI:1841975547
Name:GONYEA, EMERSON JACK (DDS)
Entity type:Individual
Prefix:
First Name:EMERSON
Middle Name:JACK
Last Name:GONYEA
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 1:4103 2ND PL NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-7561
Mailing Address - Country:US
Mailing Address - Phone:507-316-1306
Mailing Address - Fax:
Practice Address - Street 1:515 DELAWARE ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0357
Practice Address - Country:US
Practice Address - Phone:612-625-2495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR8511223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics