Provider Demographics
NPI:1861564429
Name:FUENTES, GUSTAVO ENRIQUE (DMD)
Entity type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:ENRIQUE
Last Name:FUENTES
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13650 METROPOLIS AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4375
Mailing Address - Country:US
Mailing Address - Phone:239-561-3636
Mailing Address - Fax:239-561-3699
Practice Address - Street 1:13650 METROPOLIS AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4375
Practice Address - Country:US
Practice Address - Phone:239-561-3636
Practice Address - Fax:239-561-3699
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN124981223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics