Healthcare Provider Details

I. General information

NPI: 1073205118
Provider Name (Legal Business Name): IVETH MAGALY GONZALEZ DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 WEST AVE
COCOA FL
32927-4991
US

IV. Provider business mailing address

780 WEST AVE
COCOA FL
32927-4991
US

V. Phone/Fax

Practice location:
  • Phone: 321-631-5600
  • Fax:
Mailing address:
  • Phone: 512-762-0381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN30246
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: