Provider Demographics
NPI:1255901047
Name:PEREZ GUTIERREZ, ELAINE
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:PEREZ GUTIERREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18895 NW 77TH CT
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-5281
Mailing Address - Country:US
Mailing Address - Phone:941-320-1892
Mailing Address - Fax:
Practice Address - Street 1:2627 NE 203RD ST STE 112
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1945
Practice Address - Country:US
Practice Address - Phone:305-339-5701
Practice Address - Fax:305-394-6106
Is Sole Proprietor?:No
Enumeration Date:2021-06-25
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice