MEDICARE: DR. RYAN JOSEPH GONZALEZ D.D.S.

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	1223G0001X	General Practice Dentistry	5471-015	WI

General Provider Information

NPI Number	:	1497725063
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RYAN JOSEPH GONZALEZ D.D.S.

Provider Business Mailing Address
First Line	:	902 E. MAIN STREET
Second Line	:	PO BOX
City	:	WINNECONNE
State	:	WI
Zip	:	54986
Country	:	US
Telephone Number	:	920-582-4427
Fax Number	:	920-582-7563

Provider Business Practice Location Address
First Line	:	902 E MAIN ST
Second Line	:
City	:	WINNECONNE
State	:	WI
Zip	:	54986-9782
Country	:	US
Telephone Number	:	920-582-4427
Fax Number	:	920-582-7563

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

Provider Enumeration Date	:	01/25/2006
Last Update Date	:	04/05/2019

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