Healthcare Provider Details

I. General information

NPI: 1902951528
Provider Name (Legal Business Name): MARY ELIZABETH HETSKO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 N 10TH STREET
FORT SUMNER NM
88119
US

IV. Provider business mailing address

7806 ALASKA CT APT B
CLOVIS NM
88101-8492
US

V. Phone/Fax

Practice location:
  • Phone: 505-355-7779
  • Fax: 505-355-7894
Mailing address:
  • Phone: 505-355-7779
  • Fax: 505-355-7894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2745
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: