Provider Demographics
NPI:1194713040
Name:GUTIERREZ, ELOY R JR (DDS)
Entity type:Individual
Prefix:DR
First Name:ELOY
Middle Name:R
Last Name:GUTIERREZ
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:ELOY
Other - Middle Name:R
Other - Last Name:GUTIERREZ
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:5900 CANYON CREEK DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-6614
Mailing Address - Country:US
Mailing Address - Phone:505-822-8599
Mailing Address - Fax:
Practice Address - Street 1:1441 CARLISLE BLVD NE
Practice Address - Street 2:SUITE B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5610
Practice Address - Country:US
Practice Address - Phone:505-255-9860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM11991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM008358Medicaid
NM81810Medicaid