MEDICARE: EDELIO GONZALEZ DMD, PA

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	122300000X	Dentist	DN00013074	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871684183
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDELIO GONZALEZ DMD, PA

Provider Business Mailing Address
First Line	:	1191 W 37TH ST
Second Line	:	5
City	:	HIALEAH
State	:	FL
Zip	:	33012-4941
Country	:	US
Telephone Number	:	305-826-9642
Fax Number	:	305-819-8014

Provider Business Practice Location Address
First Line	:	1191 W 37TH ST
Second Line	:	5
City	:	HIALEAH
State	:	FL
Zip	:	33012-4941
Country	:	US
Telephone Number	:	305-826-9642
Fax Number	:	305-819-8014

Authorized Official
Title or Position	:	PRESIDENT
Name	:	EDELIO GONZALEZ
Credential	:	DMD
Telephone Number	:	305-826-9642

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	08/22/2020

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