MEDICARE: DR. WAYNE DAVID GONZALES DDS

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	1223P0700X	Prosthodontics	104439	CA
2	1223G0001X	General Practice Dentistry	104439	CA

General Provider Information

NPI Number	:	1083255111
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WAYNE DAVID GONZALES DDS

Provider Business Mailing Address
First Line	:	3732 WESTWOOD BLVD APT 5
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-6720
Country	:	US
Telephone Number	:	310-948-5765
Fax Number	:

Provider Business Practice Location Address
First Line	:	8031 LINDA VISTA RD # 210
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-5110
Country	:	US
Telephone Number	:	858-268-5020
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2019
Last Update Date	:	10/28/2019

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