Provider Demographics
NPI:1104344290
Name:MARTIN G. GUTIERREZ
Entity type:Organization
Organization Name:MARTIN G. GUTIERREZ
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:646-204-8024
Mailing Address - Street 1:4275 EXECUTIVE SQUARE
Mailing Address - Street 2:STE 200
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9123
Mailing Address - Country:US
Mailing Address - Phone:618-488-3200
Mailing Address - Fax:866-272-6924
Practice Address - Street 1:145-8 BLVD. CARRONZA
Practice Address - Street 2:AVIACION
Practice Address - City:ENSENADA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22840
Practice Address - Country:MX
Practice Address - Phone:646-204-8024
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-08
Last Update Date:2017-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ08805377122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty