Healthcare Provider Details

I. General information

NPI: 1972293322
Provider Name (Legal Business Name): ITZEL GUTIERREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2023
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 GREYROCK PL
STAMFORD CT
06901-3100
US

IV. Provider business mailing address

127 GREYROCK PL
STAMFORD CT
06901-3100
US

V. Phone/Fax

Practice location:
  • Phone: 203-340-1506
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI03152800
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14862
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number22DI03152800
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number14862
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: