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General NPI Number Information
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NPI Number | 1790136745
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Entity Type | Individual
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Provider Name | JESSICA GONZALES
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Gender | Female
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Dates
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Enumeration Date | 06/30/2016
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Last Update Date | 06/30/2016
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Provider Practice Location Address
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Address Line | 4800 CUTLER AVE NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87110-4033
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Country | US
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Telephone | 505-881-1234
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Fax |
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Provider Business Mailing Address
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Address Line | 10212 HACKAMORE PL SW
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City | ALBUQUERQUE
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State | NM
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Zip | 87121-8931
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Country | US
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Telephone | 505-620-0552
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | DH4066
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License Number State | NM
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