Provider Demographics
NPI:1861191728
Name:GONZALES, ALEXIS LOUISE-NICOLE
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:LOUISE-NICOLE
Last Name:GONZALES
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 1:4008A ANDREWS LN
Mailing Address - Street 2:
Mailing Address - City:JB MDL
Mailing Address - State:NJ
Mailing Address - Zip Code:08641-1116
Mailing Address - Country:US
Mailing Address - Phone:423-343-3440
Mailing Address - Fax:
Practice Address - Street 1:3452 BROIDY RD
Practice Address - Street 2:
Practice Address - City:JOINT BASE MDL
Practice Address - State:NJ
Practice Address - Zip Code:08641-5305
Practice Address - Country:US
Practice Address - Phone:609-342-6467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-01
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX404941223G0001X
NJ22DI030798001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice