Provider Demographics
NPI:1598891509
Name:GUTIERREZ, JEREL D (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEREL
Middle Name:D
Last Name:GUTIERREZ
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 1:200 CARMICHAEL WAY STE 612
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23322-2489
Mailing Address - Country:US
Mailing Address - Phone:757-204-7210
Mailing Address - Fax:757-204-7213
Practice Address - Street 1:200 CARMICHAEL WAY STE 612
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23322-2489
Practice Address - Country:US
Practice Address - Phone:757-204-7210
Practice Address - Fax:757-204-7213
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411448122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1865742OtherUNITED CONCORDIA
VA238989OtherANTEM BC & BS OF VA
VA11448OtherDELTA