MEDICARE: ANA GONZALEZ

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	8446	SC

General Provider Information

NPI Number	:	1164803789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANA GONZALEZ

Provider Business Mailing Address
First Line	:	670 HARBOR CREEK PL
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29412-3203
Country	:	US
Telephone Number	:	321-277-1564
Fax Number	:

Provider Business Practice Location Address
First Line	:	670 HARBOR CREEK PL
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29412-3203
Country	:	US
Telephone Number	:	321-277-1564
Fax Number	:

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

Provider Enumeration Date	:	06/10/2015
Last Update Date	:	06/10/2015

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