Healthcare Provider Details

I. General information

NPI: 1689345258
Provider Name (Legal Business Name): GUTIERREZ ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 09/23/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 SONOMA RANCH BLVD SUITE A
LAS CRUCES NM
88011-8801
US

IV. Provider business mailing address

4041 DEMOS AVE
LAS CRUCES NM
88011-4210
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. LUIS GUTIERREZ PULIDO
Title or Position: ORTHODONTIST
Credential: DDS
Phone: 650-477-4101