Healthcare Provider Details

I. General information

NPI: 1457551491
Provider Name (Legal Business Name): JOSE RICARDO GONZALEZ, D.D.S., A DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2007
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2735 N. BLACKSTONE AVE
FRESNO CA
93703
US

IV. Provider business mailing address

2735 N. BLACKSTONE AVE
FRESNO CA
93703
US

V. Phone/Fax

Practice location:
  • Phone: 559-225-3391
  • Fax: 559-225-1601
Mailing address:
  • Phone: 559-225-3391
  • Fax: 559-225-1601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number47263
License Number StateCA

VIII. Authorized Official

Name: JOSE RICARDO GONZALEZ
Title or Position: CEO
Credential: DDS
Phone: 559-970-5072