Provider Demographics
NPI:1588320311
Name:GONZALEZ, VERONICA
Entity type:Individual
Prefix:
First Name:VERONICA
Middle Name:
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 1:3045 S ARCHIBALD AVE STE H289
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-9001
Mailing Address - Country:US
Mailing Address - Phone:909-758-8075
Mailing Address - Fax:909-610-8448
Practice Address - Street 1:JOSE CLEMENTE OROZCO TORRE 7 # 2230, STE 301
Practice Address - Street 2:
Practice Address - City:TIJUANA
Practice Address - State:BAJA CA
Practice Address - Zip Code:22010
Practice Address - Country:MX
Practice Address - Phone:909-758-8075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3620678122300000X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentistGroup - Single Specialty