Healthcare Provider Details

I. General information

NPI: 1548302813
Provider Name (Legal Business Name): DENNIS N. QUINTANA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HC 74 BOX 21014
EL PRADO NM
87529-9510
US

IV. Provider business mailing address

HC 74 BOX 21014
EL PRADO NM
87529-9510
US

V. Phone/Fax

Practice location:
  • Phone: 505-751-0461
  • Fax:
Mailing address:
  • Phone: 505-751-0461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number585
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: