Healthcare Provider Details

I. General information

NPI: 1932485430
Provider Name (Legal Business Name): DEL D SKINNER RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2011
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608-B LA JOYA ST EL CENTRO FAMILY HEALTH ESPANOLA DENTAL
ESPANOLA NM
87532-3467
US

IV. Provider business mailing address

PO BOX 158 538 N. PASEO DE ONATE
ESPANOLA NM
87532-0158
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-9454
  • Fax: 505-753-0850
Mailing address:
  • Phone: 505-753-7218
  • Fax: 505-753-5815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH2481
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: