MEDICARE: DR. EMERSON VICUNA D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DD2358	NM

General Provider Information

NPI Number	:	1366561060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EMERSON VICUNA D.D.S.

Provider Business Mailing Address
First Line	:	6804 BRUSHFIELD RD NW
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87114-3931
Country	:	US
Telephone Number	:	505-898-2389
Fax Number	:

Provider Business Practice Location Address
First Line	:	1010 BRIDGE BLVD SW
Second Line	:	STE F
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87105-3765
Country	:	US
Telephone Number	:	505-877-1113
Fax Number	:	505-877-1813

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	07/08/2007

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