Healthcare Provider Details

I. General information

NPI: 1356401194
Provider Name (Legal Business Name): VALERIE NICOLE LAPOLLA D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VINCENT NICHOLAS LAPOLLA D.D.S.

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RR 5 BOX 446 SANTA CLARA HEALTH CENTER
ESPANOLA NM
87532-8908
US

IV. Provider business mailing address

RR 5 BOX 446 SANTA CLARA HEALTH CENTER
ESPANOLA NM
87532-8908
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-9421
  • Fax: 505-753-5039
Mailing address:
  • Phone: 505-753-9421
  • Fax: 505-753-5039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number20479
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: