Provider Demographics
NPI:1912969502
Name:GONZALES, THERESA SULLIVAN (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:SULLIVAN
Last Name:GONZALES
Suffix:
Gender:F
Credentials:DMD, MS
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Other - Credentials:
Mailing Address - Street 1:PO BOX 751461
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1461
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:173 ASHLEY AVENUE MSC 507
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401
Practice Address - Country:US
Practice Address - Phone:843-792-8723
Practice Address - Fax:843-792-3697
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX175661223P0106X
SC26481223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology