MEDICARE: CUAUHTEMOC GONZALEZ 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	1223P0221X	Pediatric Dentistry	101166	CA

General Provider Information

NPI Number	:	1366839193
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CUAUHTEMOC GONZALEZ DDS

Provider Business Mailing Address
First Line	:	5420 PARK DR
Second Line	:
City	:	ROCKLIN
State	:	CA
Zip	:	95765-5562
Country	:	US
Telephone Number	:	916-435-5230
Fax Number	:

Provider Business Practice Location Address
First Line	:	5420 PARK DR
Second Line	:
City	:	ROCKLIN
State	:	CA
Zip	:	95765-5562
Country	:	US
Telephone Number	:	916-435-5230
Fax Number	:

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

Provider Enumeration Date	:	04/20/2015
Last Update Date	:	07/15/2022

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