1114198868 NPI number — GUTIERREZ, VICENCIO D.D.S INC

Table of content: (NPI 1114198868)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114198868 NPI number — GUTIERREZ, VICENCIO D.D.S INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUTIERREZ, VICENCIO D.D.S INC
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:
WHITTIER MAGIC SMILE
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:
1114198868
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11156 WHITTIER BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITTIER
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90606-1432
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-692-5311
Provider Business Mailing Address Fax Number:
562-692-2425

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11156 WHITTIER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WHITTIER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90606-1432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-692-5311
Provider Business Practice Location Address Fax Number:
562-692-2425
Provider Enumeration Date:
03/20/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GUTIERREZ
Authorized Official First Name:
MARTHA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
562-692-5311

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  D44176 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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