Provider Demographics
NPI:1568975613
Name:LIVIO A. GUTIERREZ
Entity Type:Organization
Organization Name:LIVIO A. GUTIERREZ
Other - Org Name:LIVIO A. GUTIERREZ DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:LIVIO
Authorized Official - Middle Name:A
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:664-634-7510
Mailing Address - Street 1:4275 EXECUTIVE SQUARE
Mailing Address - Street 2:STE 200
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9123
Mailing Address - Country:US
Mailing Address - Phone:619-488-3200
Mailing Address - Fax:866-272-6924
Practice Address - Street 1:AVE JOSE CLEMENTE OROZCO 2340 SUITE 501
Practice Address - Street 2:ZONA RIO
Practice Address - City:TIJUANA
Practice Address - State:BAJA CALIFORNIA
Practice Address - Zip Code:22010
Practice Address - Country:MX
Practice Address - Phone:664-634-7510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ7576817122300000X
ZZ105009731223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty