Provider Demographics
NPI:1649436999
Name:GONZALES, JUSTIN D (DMD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:D
Last Name:GONZALES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2051 KAEN RD
Mailing Address - Street 2:SUITE 367
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-4035
Mailing Address - Country:US
Mailing Address - Phone:503-742-5300
Mailing Address - Fax:503-742-5979
Practice Address - Street 1:9775 SE SUNNYSIDE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5739
Practice Address - Country:US
Practice Address - Phone:503-655-8471
Practice Address - Fax:503-794-3850
Is Sole Proprietor?:No
Enumeration Date:2008-08-05
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORD90891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice