=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134220452
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GINA GONZALEZ D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 WILSHIRE BLVD 440
-----------------------------------------------------
City | SANTA MONICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90401-1872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-451-5557
-----------------------------------------------------
Fax | 310-451-1158
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16673 CALLE HALEIGH
-----------------------------------------------------
City | PACIFIC PALISADES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90272-1968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-573-1200
-----------------------------------------------------
Fax | 310-573-1744
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 39153
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------