Provider Demographics
NPI:1447980677
Name:GONZALEZ, RAYMOND (DMD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 MONICA ST
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33954-1220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1750 TAMIAMI TRL STE 100
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-1045
Practice Address - Country:US
Practice Address - Phone:941-235-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-11
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN27060122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program