Healthcare Provider Details

I. General information

NPI: 1730556515
Provider Name (Legal Business Name): GUADALUPE GUTIERREZ II DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2015
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 N FRUITLAND LN
COEUR D ALENE ID
83815-7914
US

IV. Provider business mailing address

9530 S EASTERN AVE STE 160
LAS VEGAS NV
89123-8036
US

V. Phone/Fax

Practice location:
  • Phone: 208-765-3301
  • Fax:
Mailing address:
  • Phone: 725-331-3291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD4664
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7888
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: