Provider Demographics
NPI:1194111815
Name:M SYLVESTER GONZALES DDS PA
Entity type:Organization
Organization Name:M SYLVESTER GONZALES DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:SYLVESTER
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-501-4020
Mailing Address - Street 1:4010 SANDY BROOK DR. #104
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-1517
Mailing Address - Country:US
Mailing Address - Phone:512-501-4020
Mailing Address - Fax:512-501-4021
Practice Address - Street 1:4010 SANDY BROOK DR. #104
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78665-1517
Practice Address - Country:US
Practice Address - Phone:512-501-4020
Practice Address - Fax:512-501-4020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-09
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22311122300000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1053437814OtherNPI