1255450557 NPI number — DR. CARLA W. GONZALEZ DDS

Table of content: DR. CARLA W. GONZALEZ DDS (NPI 1255450557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255450557 NPI number — DR. CARLA W. GONZALEZ DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALEZ
Provider First Name:
CARLA
Provider Middle Name:
W.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BUSTILLO-GONZALEZ
Provider Other First Name:
CARLA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.D.S.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1255450557
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1455 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TEWKSBURY
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
01876
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
978-851-7112
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1455 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TEWKSBURY
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01876-4769
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
978-851-7112
Provider Business Practice Location Address Fax Number:
978-851-7112
Provider Enumeration Date:
03/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  20116 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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