Basic Information
| Provider Information | |||||||||
| NPI: | 1679725196 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | JESUS | ||||||||
| MiddleName: | MANUEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS, MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21515 DAVIS MILL RD | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208764419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6197231550 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5250 BLANCO RD | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782167017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2103493368 | ||||||||
| FaxNumber: | 2103492473 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2008 | ||||||||
| LastUpdateDate: | 12/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 24142 | TX | N | Dental Providers | Dentist | 204E00000X | S0161 | TX | N | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery | 1223S0112X | 24142 | TX | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
No ID Information.