Provider Demographics
NPI:1689768780
Name:GUTIERREZ, JUAN CARLOS (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:CARLOS
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 1:14001 SHADOW GLEN BLVD
Mailing Address - Street 2:
Mailing Address - City:MANOR
Mailing Address - State:TX
Mailing Address - Zip Code:78653-3376
Mailing Address - Country:US
Mailing Address - Phone:512-278-8700
Mailing Address - Fax:
Practice Address - Street 1:14001 SHADOW GLEN BLVD
Practice Address - Street 2:
Practice Address - City:MANOR
Practice Address - State:TX
Practice Address - Zip Code:78653-3376
Practice Address - Country:US
Practice Address - Phone:512-278-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23582122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist