Healthcare Provider Details

I. General information

NPI: 1063645455
Provider Name (Legal Business Name): ELMER ELEAZAR GONZALEZ PH.D, RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2009
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 S ESPINA ST
LAS CRUCES NM
88003-1290
US

IV. Provider business mailing address

3400 S ESPINA ST
LAS CRUCES NM
88003-1290
US

V. Phone/Fax

Practice location:
  • Phone: 575-528-7071
  • Fax:
Mailing address:
  • Phone: 575-528-7071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH3025
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: