Provider Demographics
NPI:1194316075
Name:GONZALEZ, ASIAH JEANMARIE (LDT)
Entity type:Individual
Prefix:
First Name:ASIAH
Middle Name:JEANMARIE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:LDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17395 RESERVATION RD
Mailing Address - Street 2:
Mailing Address - City:LA CONNER
Mailing Address - State:WA
Mailing Address - Zip Code:98257-8802
Mailing Address - Country:US
Mailing Address - Phone:360-466-3900
Mailing Address - Fax:
Practice Address - Street 1:17395 RESERVATION RD
Practice Address - Street 2:
Practice Address - City:LA CONNER
Practice Address - State:WA
Practice Address - Zip Code:98257-8802
Practice Address - Country:US
Practice Address - Phone:360-466-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA19-TDT-02125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist