=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881406437
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUIS JORGE GAXIOLA RUIZ
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2025
-----------------------------------------------------
Last Update Date | 01/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | ALVARO OBREGON 98-6
-----------------------------------------------------
City | NOGALES
-----------------------------------------------------
State | SONORA
-----------------------------------------------------
Zip | 84030
-----------------------------------------------------
Country | MX
-----------------------------------------------------
Telephone | 619-272-9021
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 675 E MAYA ST
-----------------------------------------------------
City | NOGALES
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85621-3360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. LUIS JORGE GAXIOLA RUIZ
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 619-272-9021
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------