Provider Demographics
NPI:1285110718
Name:GONZALEZ, CARMEN LIEN
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:LIEN
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13701 SW 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-2704
Mailing Address - Country:US
Mailing Address - Phone:786-416-2385
Mailing Address - Fax:
Practice Address - Street 1:13701 SW 12TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33184-2704
Practice Address - Country:US
Practice Address - Phone:786-416-2385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN23700122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist