Mauricio Gonzalez Balut, DDS, MS

Primary specialty

Orthodontics and Dentofacial Orthopedics DentistryTaxonomy code 1223X0400X

License

SP313 Issued in CA

Practice address

159 W Hospitality LN Ste 100
San Bernardino, CA 92408-3348

Phone

(909) 558-4960

NPI assigned

Feb 1, 2024

Last updated

Feb 1, 2024By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Master of Science

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1706745600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1706745600000",
    "number": "1770346843",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11092 ANDERSON ST",
            "city": "LOMA LINDA",
            "state": "CA",
            "postal_code": "923501706",
            "telephone_number": "909-558-4603",
            "fax_number": "909-558-4822"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "159 W HOSPITALITY LN STE 100",
            "city": "SAN BERNARDINO",
            "state": "CA",
            "postal_code": "924083348",
            "telephone_number": "909-558-4960"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "11092 Anderson St",
            "address_purpose": "LOCATION",
            "city": "Loma Linda",
            "state": "CA",
            "postal_code": "923501706",
            "country_code": "US",
            "telephone_number": "909-558-4603",
            "fax_number": "909-558-4822",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "GONZALEZ BALUT",
        "first_name": "MAURICIO",
        "credential": "DDS, MS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2024-02-01",
        "last_updated": "2024-02-01",
        "certification_date": "2024-02-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223X0400X",
            "taxonomy_group": "",
            "desc": "Dentist, Orthodontics and Dentofacial Orthopedics",
            "state": "CA",
            "license": "SP313",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jasmine Megan Gonzales
• Jessica Mary Gonzales
• Mariza Gonzales
• Richard Edward Gonzales
• Trisha Gonzales
• Giselle Gonzalez Sevilla
• Abraham Isacc Gonzalez, REGISTERED NURSE
• Adriana Gonzalez
• Alexandra Gonzalez
• Alina Marie Gonzalez

• Orthodontics and Dentofacial Orthopedics Dentistry in San Bernardino, CA
• Providers in San Bernardino, CA by specialty
• Orthodontics and Dentofacial Orthopedics Dentistry in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 1, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.