Provider Demographics
NPI:1487811352
Name:GONZALEZ-NIETO, GUSTAVO ALBERTO (DDS)
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:ALBERTO
Last Name:GONZALEZ-NIETO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 N 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:TEAGUE
Mailing Address - State:TX
Mailing Address - Zip Code:75860-1601
Mailing Address - Country:US
Mailing Address - Phone:254-739-2533
Mailing Address - Fax:254-739-2534
Practice Address - Street 1:109 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:TEAGUE
Practice Address - State:TX
Practice Address - Zip Code:75860-1601
Practice Address - Country:US
Practice Address - Phone:254-739-2533
Practice Address - Fax:254-739-2534
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX238631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice