Healthcare Provider Details

I. General information

NPI: 1891776225
Provider Name (Legal Business Name): PATRICIA B VALDIVIA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 BONITA ST
GRANTS NM
87020-2103
US

IV. Provider business mailing address

1209 BONITA ST
GRANTS NM
87020-2103
US

V. Phone/Fax

Practice location:
  • Phone: 505-876-4034
  • Fax: 505-876-4036
Mailing address:
  • Phone: 505-285-6937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD1637
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: