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General NPI Number Information
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NPI Number | 1871088419
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Entity Type | Individual
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Provider Name | GUSTAVO VASQUEZ SIDA DMD
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Gender | Male
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Dates
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Enumeration Date | 06/26/2018
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Last Update Date | 10/22/2019
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Provider Practice Location Address
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Address Line | 1998 N MOTEL BLVD
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City | LAS CRUCES
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State | NM
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Zip | 88007
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Country | US
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Telephone | 575-541-5941
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Fax | 575-541-5048
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Provider Business Mailing Address
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Address Line | PO BOX 370
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City | HATCH
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State | NM
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Zip | 87937-0370
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Country | US
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Telephone | 575-267-3280
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Fax | 575-267-1747
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D010085
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DD5149
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License Number State | NM
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