Healthcare Provider Details

I. General information

NPI: 1225158348
Provider Name (Legal Business Name): PUEBLO OF ISLETA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 05/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

01 SAGEBRUSH RD
ISLETA NM
87022-0000
US

IV. Provider business mailing address

01 SAGEBRUSH RD
ISLETA NM
87022-0000
US

V. Phone/Fax

Practice location:
  • Phone: 505-869-4863
  • Fax:
Mailing address:
  • Phone: 505-869-4863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number501C
License Number StateNM

VIII. Authorized Official

Name: MRS. VOLELLE K ZAMORA
Title or Position: CEO
Credential:
Phone: 505-869-4094