Healthcare Provider Details

I. General information

NPI: 1205628245
Provider Name (Legal Business Name): CRISTAL GONZALEZ NUNEZ DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2025
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 MAIN ST
MIDDLETOWN CT
06457-2732
US

IV. Provider business mailing address

19 GRAND ST
MIDDLETOWN CT
06457-2705
US

V. Phone/Fax

Practice location:
  • Phone: 860-347-6971
  • Fax: 860-343-7379
Mailing address:
  • Phone: 860-347-6971
  • Fax: 860-343-7379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14856
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: