Provider Demographics
NPI:1497973879
Name:WUTZKE, GERHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:GERHARD
Middle Name:
Last Name:WUTZKE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 N. SEPULVEDA BLVD.
Mailing Address - Street 2:SUITE 1800
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245
Mailing Address - Country:US
Mailing Address - Phone:800-373-5400
Mailing Address - Fax:888-492-2900
Practice Address - Street 1:222 N. SEPULVEDA BLVD.
Practice Address - Street 2:SUITE 1800
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245
Practice Address - Country:US
Practice Address - Phone:800-373-5400
Practice Address - Fax:888-492-2900
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18672122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist