MEDICARE: DR. PETER CHARLES GONZALEZ DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223D0001X	Public Health Dentistry	105104	CA
2	1223G0001X	General Practice Dentistry	D11588	OR

General Provider Information

NPI Number	:	1720540818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PETER CHARLES GONZALEZ DDS

Provider Business Mailing Address
First Line	:	5232 S 6TH ST
Second Line	:
City	:	KLAMATH FALLS
State	:	OR
Zip	:	97603-5002
Country	:	US
Telephone Number	:	321-704-1974
Fax Number	:

Provider Business Practice Location Address
First Line	:	5232 S 6TH ST
Second Line	:
City	:	KLAMATH FALLS
State	:	OR
Zip	:	97603-5002
Country	:	US
Telephone Number	:	321-704-1974
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2019
Last Update Date	:	09/16/2022

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