Provider Demographics
NPI:1568558807
Name:GONZALEZ-VILLARREAL, LYDIA LINDA (DDS)
Entity type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:LINDA
Last Name:GONZALEZ-VILLARREAL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17603 KRUGERRAND DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232
Mailing Address - Country:US
Mailing Address - Phone:210-525-1600
Mailing Address - Fax:
Practice Address - Street 1:5250 BLANCO RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-7017
Practice Address - Country:US
Practice Address - Phone:210-621-8821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX147091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX008159801Medicaid
TX000112292OtherAETNA INS
TX0003379OtherMANAGED DENTAL GAURD
TX051115OtherGOVT CHIP PROGRAM