Healthcare Provider Details

I. General information

NPI: 1861191728
Provider Name (Legal Business Name): ALEXIS LOUISE-NICOLE GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2023
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MADISON AVE STE A
MOUNT HOLLY NJ
08060-2055
US

IV. Provider business mailing address

4008A ANDREWS LN
JB MDL NJ
08641-1116
US

V. Phone/Fax

Practice location:
  • Phone: 609-905-4233
  • Fax:
Mailing address:
  • Phone: 423-343-3440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI03079800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number40494
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: