MEDICARE: GUSTAVO RUIZ DE CASTILLA DMD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics

General Provider Information

NPI Number	:	1659816429
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GUSTAVO RUIZ DE CASTILLA DMD PA

Provider Business Mailing Address
First Line	:	3814 W AZEELE ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-3922
Country	:	US
Telephone Number	:	813-289-3640
Fax Number	:	813-872-0170

Provider Business Practice Location Address
First Line	:	3814 W AZEELE ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-3922
Country	:	US
Telephone Number	:	813-289-3640
Fax Number	:	813-872-0170

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. GUSTAVO RUIZ DE CASTILLA
Credential	:	DMD
Telephone Number	:	813-289-3640

Provider Enumeration Date	:	01/03/2017
Last Update Date	:	01/03/2017

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