Healthcare Provider Details

I. General information

NPI: 1669696951
Provider Name (Legal Business Name): TULAROSA BASIN DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 9TH ST SUITE A
ALAMOGORDO NM
88310-5842
US

IV. Provider business mailing address

1212 9TH ST SUITE A
ALAMOGORDO NM
88310-5842
US

V. Phone/Fax

Practice location:
  • Phone: 505-437-6700
  • Fax: 505-437-6644
Mailing address:
  • Phone: 505-437-6700
  • Fax: 505-437-6644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA115701
License Number StateNM

VIII. Authorized Official

Name: DR. JENNIFER L. TONCRAY
Title or Position: PRESIDENT
Credential: D.O.
Phone: 505-437-6700