Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 104439 | CA |
Y | 213EG0000X | General Practice | 104439 | CA |
N | 1223P0700X | Prosthodontist | 104439 | CA |
NPI | 1083255111 |
---|---|
Provider Name | Dr. Wayne David Gonzales |
First Address | Los Angeles, CA 90034-6720 |
Second Address | San Diego, CA 92111-5110 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/09/2019 |
Last Update Date | 28/10/2019 |