Provider Demographics
NPI:1952717027
Name:GONZALEZ, KELLY (DMD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name: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 1:511 SE 5TH AVE APT 1122
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-2972
Mailing Address - Country:US
Mailing Address - Phone:561-212-8478
Mailing Address - Fax:954-846-7129
Practice Address - Street 1:12801 W SUNRISE BLVD
Practice Address - Street 2:F222
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-4020
Practice Address - Country:US
Practice Address - Phone:954-846-7171
Practice Address - Fax:954-846-7129
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN201701223G0001X
FLDN20710122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice