Healthcare Provider Details

I. General information

NPI: 1639361371
Provider Name (Legal Business Name): SMALL FRY DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2007
Last Update Date: 08/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 LINDA DR
GALLUP NM
87301-5615
US

IV. Provider business mailing address

1401 LINDA DR
GALLUP NM
87301-5615
US

V. Phone/Fax

Practice location:
  • Phone: 505-870-6128
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2150
License Number StateNM

VIII. Authorized Official

Name: DR. EDUARDO VALDA
Title or Position: OWNER
Credential: DDS
Phone: 505-870-6128