MEDICARE: LUNA GONZALO 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	122300000X	Dentist	567068	TX

General Provider Information

NPI Number	:	1508079377
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LUNA GONZALO DDS

Provider Business Mailing Address
First Line	:	1120 WILL RAND DR
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-7620
Country	:	US
Telephone Number	:	915-449-8589
Fax Number	:	915-833-8796

Provider Business Practice Location Address
First Line	:	2800 PEDRO S VARELA
Second Line	:
City	:	JUAREZ
State	:	CHIHUAHUA
Zip	:	32300
Country	:	MX
Telephone Number	:	011526566166140
Fax Number	:

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

Provider Enumeration Date	:	05/08/2007
Last Update Date	:	07/08/2007

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