MEDICARE: DR. JUAN CARLOS GONZALEZ DMD

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	DN19791	FL

General Provider Information

NPI Number	:	1306100441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUAN CARLOS GONZALEZ DMD

Provider Business Mailing Address
First Line	:	2734 NW 22ND AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33142-8433
Country	:	US
Telephone Number	:	305-638-9793
Fax Number	:	305-638-9994

Provider Business Practice Location Address
First Line	:	2734 NW 22ND AVE
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33142-8433
Country	:	US
Telephone Number	:	305-638-9793
Fax Number	:	305-638-9994

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

Provider Enumeration Date	:	07/03/2012
Last Update Date	:	07/03/2012

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