Healthcare Provider Details

I. General information

NPI: 1750526117
Provider Name (Legal Business Name): FAY L HARRIS DENTAL HYGIENIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2008
Last Update Date: 12/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 LA JOYA ST STE B
ESPANOLA NM
87532-3467
US

IV. Provider business mailing address

P.O. BOX 1271 142 MAPLE STREET
CHAMA NM
87520-3467
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-9454
  • Fax: 505-753-5815
Mailing address:
  • Phone: 575-756-1957
  • Fax: 505-753-5815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH465
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: