Healthcare Provider Details

I. General information

NPI: 1093240665
Provider Name (Legal Business Name): DANIEL GUTIERREZ SOLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2017
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5355 KENT AVE
RIVERSIDE CA
92503-2428
US

IV. Provider business mailing address

5355 KENT AVE
RIVERSIDE CA
92503-2428
US

V. Phone/Fax

Practice location:
  • Phone: 951-675-8020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number77894
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: