1104344290 NPI number — MARTIN G. GUTIERREZ

Table of content: (NPI 1104344290)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104344290 NPI number — MARTIN G. GUTIERREZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARTIN G. GUTIERREZ
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MARTIN G. GUTIERREZ D.D.S.
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104344290
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4275 EXECUTIVE SQUARE
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
LA JOLLA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92037-9123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-488-3200
Provider Business Mailing Address Fax Number:
866-272-6924

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
145-8 BLVD. CARRONZA
Provider Second Line Business Practice Location Address:
AVIACION
Provider Business Practice Location Address City Name:
ENSENADA
Provider Business Practice Location Address State Name:
BAJA CALIFORNIA
Provider Business Practice Location Address Postal Code:
22840
Provider Business Practice Location Address Country Code:
MX
Provider Business Practice Location Address Telephone Number:
646-204-8024
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/08/2017

Additional Information

Authorized Official

Authorized Official Last Name:
GUTIERREZ
Authorized Official First Name:
MARTIN
Authorized Official Middle Name:
G
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
646-204-8024

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  08805377 , registered in the state of ZZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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