=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255676268
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSE MARIO GUTIERREZ III D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2012
-----------------------------------------------------
Last Update Date | 12/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7703 FLOYD CURL DR (MSC 7914)
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78229-3901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-567-6300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25839 ECHO MTN
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78260-6287
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-494-4889
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 12011
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------