Provider Demographics
NPI:1730487224
Name:AVILA ORTIZ, GUSTAVO (DDS, MS, PHD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:AVILA ORTIZ
Suffix:
Gender:M
Credentials:DDS, MS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 DENTAL SCIENCE BLDG. S445
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1001
Mailing Address - Country:US
Mailing Address - Phone:319-335-7241
Mailing Address - Fax:
Practice Address - Street 1:322 DENTAL SCIENCE BLDG. S445
Practice Address - Street 2:S445
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1001
Practice Address - Country:US
Practice Address - Phone:319-335-7241
Practice Address - Fax:319-335-7239
Is Sole Proprietor?:No
Enumeration Date:2011-03-07
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA401211223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics