Healthcare Provider Details

I. General information

NPI: 1790136745
Provider Name (Legal Business Name): JESSICA GONZALES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA GONZALES RDH

II. Dates (important events)

Enumeration Date: 06/30/2016
Last Update Date: 06/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 CUTLER AVE NE
ALBUQUERQUE NM
87110-4033
US

IV. Provider business mailing address

10212 HACKAMORE PL SW
ALBUQUERQUE NM
87121-8931
US

V. Phone/Fax

Practice location:
  • Phone: 505-881-1234
  • Fax:
Mailing address:
  • Phone: 505-620-0552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH4066
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: