MEDICARE: SUSANA 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	DN17960	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457654824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSANA GONZALEZ DMD

Provider Business Mailing Address
First Line	:	16010 NW 57TH AVE UNIT 130
Second Line	:
City	:	MIAMI LAKES
State	:	FL
Zip	:	33014-6710
Country	:	US
Telephone Number	:	786-536-9411
Fax Number	:

Provider Business Practice Location Address
First Line	:	16010 NW 57TH AVE UNIT 130
Second Line	:
City	:	MIAMI LAKES
State	:	FL
Zip	:	33014-6710
Country	:	US
Telephone Number	:	786-536-9411
Fax Number	:	305-515-3997

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

Provider Enumeration Date	:	12/07/2010
Last Update Date	:	06/25/2017

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