Healthcare Provider Details

I. General information

NPI: 1205571361
Provider Name (Legal Business Name): GONZALES DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2022
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 N SARAH DEWITT DR STE 206
GONZALES TX
78629-2714
US

IV. Provider business mailing address

2401 E RANDOL MILL RD STE 520
ARLINGTON TX
76011-6380
US

V. Phone/Fax

Practice location:
  • Phone: 830-339-2007
  • Fax: 830-203-5242
Mailing address:
  • Phone: 817-809-4860
  • Fax: 682-626-1824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: BRIANNA BARROW
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 817-809-4860