Provider Demographics
NPI:1881255768
Name:GONZALEZ, JUAN MANUEL JR (DDS)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:MANUEL
Last Name:GONZALEZ
Suffix:JR
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 1:4920 ATASCOCITA RD # 900
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77346-2849
Mailing Address - Country:US
Mailing Address - Phone:281-973-6220
Mailing Address - Fax:
Practice Address - Street 1:4920 ATASCOCITA RD # 900
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77346-2849
Practice Address - Country:US
Practice Address - Phone:281-973-6220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-22
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35342122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX35342Medicaid