Healthcare Provider Details

I. General information

NPI: 1598755076
Provider Name (Legal Business Name): SAMANTHA LOPEZ-HINDS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 NORTH PINE
CHAMA NM
87520
US

IV. Provider business mailing address

PO BOX 824 #15 CNTHY RD 329
TIERRA AMARILLA NM
87575-0824
US

V. Phone/Fax

Practice location:
  • Phone: 505-756-2901
  • Fax: 505-756-2821
Mailing address:
  • Phone: 505-588-7968
  • Fax: 505-756-2821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH1220
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: