Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223P0106X | Oral and Maxillofacial Pathology | 17566 | TX |
Y | 1223P0106X | Oral and Maxillofacial Pathology | 2648 | SC |
NPI | 1912969502 |
---|---|
Provider Name | Dr. Theresa Sullivan Gonzales |
First Address | Charlotte, NC 28275-1461 |
Second Address | Charleston, SC 29401 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/04/2006 |
Last Update Date | 31/08/2016 |