Provider Demographics
NPI:1639300148
Name:LOPEZ GUTIERREZ, MARIO A (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:A
Last Name:LOPEZ 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:P.O. BOX 962707
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79335-3027
Mailing Address - Country:US
Mailing Address - Phone:915-855-8874
Mailing Address - Fax:915-921-7842
Practice Address - Street 1:17 DE MARZO #4710
Practice Address - Street 2:
Practice Address - City:CD. JUAREZ
Practice Address - State:CHIH.
Practice Address - Zip Code:32310
Practice Address - Country:MX
Practice Address - Phone:915-855-8874
Practice Address - Fax:915-921-7842
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-31
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZ1630461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
0002076802OtherUNITED CONCORDIA