Healthcare Provider Details

I. General information

NPI: 1083255111
Provider Name (Legal Business Name): WAYNE DAVID GONZALES DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2019
Last Update Date: 10/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8031 LINDA VISTA RD # 210
SAN DIEGO CA
92111-5110
US

IV. Provider business mailing address

3732 WESTWOOD BLVD APT 5
LOS ANGELES CA
90034-6720
US

V. Phone/Fax

Practice location:
  • Phone: 858-268-5020
  • Fax:
Mailing address:
  • Phone: 310-948-5765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number104439
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number104439
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: