Healthcare Provider Details

I. General information

NPI: 1417699612
Provider Name (Legal Business Name): CELES BARBONE RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2022
Last Update Date: 04/08/2022
Certification Date: 04/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1748 W MALONEY AVE
GALLUP NM
87301-3333
US

IV. Provider business mailing address

PO BOX 2071
CROWNPOINT NM
87313-2071
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-8100
  • Fax:
Mailing address:
  • Phone: 505-320-2263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH4434
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: