Healthcare Provider Details

I. General information

NPI: 1134332596
Provider Name (Legal Business Name): VALDAS CHILDRENS DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 W GREEN ST
GALLUP NM
87301-6241
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: 505-870-6128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDD2159
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDD2150
License Number StateNM

VIII. Authorized Official

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