1558853036 NPI number — PAULINA ARIADNA LARA GUTIERREZ DDS, MS

Table of content: PAULINA ARIADNA LARA GUTIERREZ DDS, MS (NPI 1558853036)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558853036 NPI number — PAULINA ARIADNA LARA GUTIERREZ DDS, MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARA GUTIERREZ
Provider First Name:
PAULINA
Provider Middle Name:
ARIADNA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS, MS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILLIAMSON
Provider Other First Name:
ARIADNA
Provider Other Middle Name:
PAULINA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS, MS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1558853036
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7610 MENTOR AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MENTOR
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44060-5411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-975-9300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7610 MENTOR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MENTOR
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44060-5411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
440-975-9300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/31/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  30.026282 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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