Healthcare Provider Details

I. General information

NPI: 1952717027
Provider Name (Legal Business Name): KELLY GONZALEZ DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12801 W SUNRISE BLVD F222
SUNRISE FL
33323-4020
US

IV. Provider business mailing address

511 SE 5TH AVE APT 1122
FORT LAUDERDALE FL
33301-2972
US

V. Phone/Fax

Practice location:
  • Phone: 954-846-7171
  • Fax: 954-846-7129
Mailing address:
  • Phone: 561-212-8478
  • Fax: 954-846-7129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN20170
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN20710
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: