Healthcare Provider Details

I. General information

NPI: 1194143222
Provider Name (Legal Business Name): LUIS D GUTIERREZ PULIDO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2014
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 E PINE ST STE B
DEMING NM
88030-7003
US

IV. Provider business mailing address

4041 DEMOS AVE
LAS CRUCES NM
88011-4210
US

V. Phone/Fax

Practice location:
  • Phone: 575-329-0840
  • Fax:
Mailing address:
  • Phone: 650-477-4101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDEN.00202164
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9414
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD5070
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: