Provider Demographics
NPI:1366543639
Name:GONZALES, THERESE A (RDH)
Entity type:Individual
Prefix:MRS
First Name:THERESE
Middle Name:A
Last Name:GONZALES
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 563
Mailing Address - Street 2:
Mailing Address - City:BRUSH
Mailing Address - State:CO
Mailing Address - Zip Code:80723
Mailing Address - Country:US
Mailing Address - Phone:970-842-0220
Mailing Address - Fax:970-842-0224
Practice Address - Street 1:412 EDISON
Practice Address - Street 2:
Practice Address - City:BRUSH
Practice Address - State:CO
Practice Address - Zip Code:80723
Practice Address - Country:US
Practice Address - Phone:970-842-0220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO904552124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01335537Medicaid