Healthcare Provider Details

I. General information

NPI: 1881406437
Provider Name (Legal Business Name): LUIS JORGE GAXIOLA RUIZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2025
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ALVARO OBREGON 98-6
NOGALES SONORA
84030
MX

IV. Provider business mailing address

675 E MAYA ST
NOGALES AZ
85621-3360
US

V. Phone/Fax

Practice location:
  • Phone: 619-272-9021
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. LUIS JORGE GAXIOLA RUIZ
Title or Position: DENTIST
Credential: DDS
Phone: 619-272-9021