Provider Demographics
NPI:1043479843
Name:JAIME GONZALEZ DDS INC
Entity type:Organization
Organization Name:JAIME GONZALEZ DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANA
Authorized Official - Middle Name:PATRICIA
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-309-0291
Mailing Address - Street 1:1516 MAIN ST STE 106A
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:CA
Mailing Address - Zip Code:92065-5242
Mailing Address - Country:US
Mailing Address - Phone:780-787-0962
Mailing Address - Fax:760-787-0851
Practice Address - Street 1:1516 MAIN ST STE 106A
Practice Address - Street 2:
Practice Address - City:RAMONA
Practice Address - State:CA
Practice Address - Zip Code:92065-5242
Practice Address - Country:US
Practice Address - Phone:780-787-0962
Practice Address - Fax:760-787-0851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55982122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty