MEDICARE: JAIME GONZALEZ DDS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	55982	CA

General Provider Information

NPI Number	:	1043479843
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAIME GONZALEZ DDS INC

Provider Business Mailing Address
First Line	:	1516 MAIN ST STE 106A
Second Line	:
City	:	RAMONA
State	:	CA
Zip	:	92065-5242
Country	:	US
Telephone Number	:	780-787-0962
Fax Number	:	760-787-0851

Provider Business Practice Location Address
First Line	:	1516 MAIN ST STE 106A
Second Line	:
City	:	RAMONA
State	:	CA
Zip	:	92065-5242
Country	:	US
Telephone Number	:	780-787-0962
Fax Number	:	760-787-0851

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	MRS. ANA PATRICIA LOPEZ
Credential	:
Telephone Number	:	617-309-0291

Provider Enumeration Date	:	06/05/2008
Last Update Date	:	06/05/2008

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