Healthcare Provider Details

I. General information

NPI: 1669181178
Provider Name (Legal Business Name): TRGONZALES DDS DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2022
Last Update Date: 11/23/2022
Certification Date: 11/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 W LAS TUNAS DR STE 107
SAN GABRIEL CA
91776-1236
US

IV. Provider business mailing address

416 W LAS TUNAS DR STE 107
SAN GABRIEL CA
91776-1236
US

V. Phone/Fax

Practice location:
  • Phone: 626-872-6352
  • Fax:
Mailing address:
  • Phone: 626-872-6352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: THOMAS GONZALES
Title or Position: AUTHORIZED OFFICIAL
Credential: DDS
Phone: 626-872-6352