Provider Demographics
NPI:1386488179
Name:GONZALEZ HERRERA, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:GONZALEZ HERRERA
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 1:8540 SW 125TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-5811
Mailing Address - Country:US
Mailing Address - Phone:786-488-1994
Mailing Address - Fax:
Practice Address - Street 1:685 CROSSWATER PKWY STE A
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-0769
Practice Address - Country:US
Practice Address - Phone:904-686-7608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN291331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice