Provider Demographics
NPI:1689267478
Name:FUENTES, GABRIEL (MOM)
Entity Type:Individual
Prefix:MR
First Name:GABRIEL
Middle Name:
Last Name:FUENTES
Suffix:
Gender:M
Credentials:MOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4430 NW 50TH ST STE M
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2295
Mailing Address - Country:US
Mailing Address - Phone:405-397-2952
Mailing Address - Fax:
Practice Address - Street 1:4430 NW 50TH ST STE M
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2295
Practice Address - Country:US
Practice Address - Phone:405-397-2952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist