Healthcare Provider Details

I. General information

NPI: 1578835500
Provider Name (Legal Business Name): OCTAVIO ALBERTO GONZALEZ D.D.S., PHD.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2012
Last Update Date: 02/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE STREET ROOM D104
LEXINGTON KY
40536-0297
US

IV. Provider business mailing address

1095 VA HEALTH SCIENCES RESEARCH BUILDING ROOM 414
LEXINGTON KY
40536-0305
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-1345
  • Fax: 859-257-5859
Mailing address:
  • Phone: 859-323-0125
  • Fax: 859-257-6566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9139
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: