Healthcare Provider Details

I. General information

NPI: 1770849796
Provider Name (Legal Business Name): ZELLISHA ALEXIS QUAM D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9169 COORS BLVD NW
ALBUQUERQUE NM
87120-3101
US

IV. Provider business mailing address

5928 NIGHT SHADOW AVE NW
ALBUQUERQUE NM
87114-1975
US

V. Phone/Fax

Practice location:
  • Phone: 505-346-2306
  • Fax: 505-346-2311
Mailing address:
  • Phone: 505-862-2467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD3884
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDD3884
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: