Healthcare Provider Details

I. General information

NPI: 1386909679
Provider Name (Legal Business Name): ANDREA GONZALEZ CARBONELL DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2012
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE 65 INFANTERIA 12 LOS FLAMBOYANES
SAN JUAN PR
00918
US

IV. Provider business mailing address

576 ARTERIAL B AVENUE COLISEUM TOWER #2203
SAN JUAN PR
00918
US

V. Phone/Fax

Practice location:
  • Phone: 787-691-0781
  • Fax:
Mailing address:
  • Phone: 787-691-0781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3052
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: