=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265533194
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK I GUTT DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 975 ARTHUR GODFREY RD SUITE #304
-----------------------------------------------------
City | MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-538-2112
-----------------------------------------------------
Fax | 305-672-6056
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 975 ARTHUR GODFREY RD SUITE #304
-----------------------------------------------------
City | MIAMI BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-538-2112
-----------------------------------------------------
Fax | 305-672-6056
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | DN0011990
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------