Healthcare Provider Details

I. General information

NPI: 1669284071
Provider Name (Legal Business Name): SELENA MALDONADO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2025
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 S ESPINA ST
LAS CRUCES NM
88003-1290
US

IV. Provider business mailing address

3400 SOUTH ESPINA STREET MSC 3DA, PO BOX 30001
LAS CRUCES NM
88003
US

V. Phone/Fax

Practice location:
  • Phone: 575-528-7071
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH4911
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: