Healthcare Provider Details

I. General information

NPI: 1417178211
Provider Name (Legal Business Name): GUSTAVO S RUIZ DE CASTILLA D.M.D., M.M.SC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4129 W KENNEDY BLVD SUITE 1
TAMPA FL
33609-2254
US

IV. Provider business mailing address

4129 W KENNEDY BLVD SUITE 1
TAMPA FL
33609-2254
US

V. Phone/Fax

Practice location:
  • Phone: 813-289-3640
  • Fax: 813-286-2241
Mailing address:
  • Phone: 813-289-3640
  • Fax: 813-286-2241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN 0012543
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: