Provider Demographics
NPI:1841852555
Name:GARCIA-GURULE, JAYSON
Entity type:Individual
Prefix:
First Name:JAYSON
Middle Name:
Last Name:GARCIA-GURULE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 DE MOSS ST
Mailing Address - Street 2:
Mailing Address - City:LORDSBURG
Mailing Address - State:NM
Mailing Address - Zip Code:88045-2617
Mailing Address - Country:US
Mailing Address - Phone:575-542-8384
Mailing Address - Fax:575-542-8387
Practice Address - Street 1:530 DE MOSS ST
Practice Address - Street 2:
Practice Address - City:LORDSBURG
Practice Address - State:NM
Practice Address - Zip Code:88045-2617
Practice Address - Country:US
Practice Address - Phone:575-542-8384
Practice Address - Fax:575-542-8387
Is Sole Proprietor?:No
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD5146122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist