Healthcare Provider Details

I. General information

NPI: 1730101726
Provider Name (Legal Business Name): SAN JUAN BASIN HEALTH DEPARTMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 CAMINO DEL RIO SOUTHWEST SMILE MAKERS
DURANGO CO
81301
US

IV. Provider business mailing address

281 SAWYER DR.
DURANGO CO
81303-3409
US

V. Phone/Fax

Practice location:
  • Phone: 970-385-4480
  • Fax: 970-247-7882
Mailing address:
  • Phone: 970-247-5702
  • Fax: 970-247-9126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. LIANE JOLLON
Title or Position: EXECUTIVE DIRECTOR
Credential: RN
Phone: 970-247-5702