Provider Demographics
NPI:1366635369
Name:GUILLEN RIVERA, GERARDO JOSE (MD)
Entity Type:Individual
Prefix:DR
First Name:GERARDO
Middle Name:JOSE
Last Name:GUILLEN RIVERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GERARDO
Other - Middle Name:JOSE
Other - Last Name:GUILLEN RIVERA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4504 PARADE WILLOW DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79922
Mailing Address - Country:US
Mailing Address - Phone:305-457-3503
Mailing Address - Fax:
Practice Address - Street 1:4504 PARADE WILLOW DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79922-2235
Practice Address - Country:US
Practice Address - Phone:305-457-3503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX284751223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery