Provider Demographics
NPI:1386830438
Name:GUTIERREZ, VICENCIO, DOMINGUEZ DDS INC
Entity Type:Organization
Organization Name:GUTIERREZ, VICENCIO, DOMINGUEZ DDS INC
Other - Org Name:SANTA ANA MAGIC SMILE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-835-6677
Mailing Address - Street 1:2112 N MAIN ST
Mailing Address - Street 2:SUITE # 100
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92706-2739
Mailing Address - Country:US
Mailing Address - Phone:714-835-6677
Mailing Address - Fax:714-558-6892
Practice Address - Street 1:2112 N MAIN ST
Practice Address - Street 2:SUITE # 100
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706-2739
Practice Address - Country:US
Practice Address - Phone:714-835-6677
Practice Address - Fax:714-558-6892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-22
Last Update Date:2007-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD44176261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental