Healthcare Provider Details

I. General information

NPI: 1124199567
Provider Name (Legal Business Name): ANTHONY D GONZALES DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 COURTHOURSE RD
LOS LUNAS NM
87031
US

IV. Provider business mailing address

PO BOX 1197
LOS LUNAS NM
87031-1197
US

V. Phone/Fax

Practice location:
  • Phone: 505-865-4341
  • Fax: 505-865-4954
Mailing address:
  • Phone: 505-865-4341
  • Fax: 505-865-4954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD1351
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: