Provider Demographics
NPI:1417178211
Name:RUIZ DE CASTILLA, GUSTAVO S (DMD, MMSC)
Entity Type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:S
Last Name:RUIZ DE CASTILLA
Suffix:
Gender:M
Credentials:DMD, MMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4129 W KENNEDY BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-2254
Mailing Address - Country:US
Mailing Address - Phone:813-289-3640
Mailing Address - Fax:813-286-2241
Practice Address - Street 1:4129 W KENNEDY BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-2254
Practice Address - Country:US
Practice Address - Phone:813-289-3640
Practice Address - Fax:813-286-2241
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 00125431223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics