Healthcare Provider Details

I. General information

NPI: 1346504693
Provider Name (Legal Business Name): MARIELA VICTORIA LEYBA RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 07/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

01 SAGEBRUSH STREET
ISLETA NM
87022
US

IV. Provider business mailing address

P.O BOX 640
ISLETA NM
87022
US

V. Phone/Fax

Practice location:
  • Phone: 505-238-2997
  • Fax:
Mailing address:
  • Phone: 505-869-3200
  • Fax: 505-869-4881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH3600
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: