Healthcare Provider Details

I. General information

NPI: 1871586248
Provider Name (Legal Business Name): LYN M. ST. LOUIS DH
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HOUSE#013405 STATE RD. 75 - HCNNM PENASCO DENTAL
PENASCO NM
87553
US

IV. Provider business mailing address

111 N RAILROAD AVE P.O. BOX 158
ESPANOLA NM
87532-2627
US

V. Phone/Fax

Practice location:
  • Phone: 505-587-2809
  • Fax: 505-587-1944
Mailing address:
  • Phone: 505-753-7218
  • Fax: 505-753-5815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH2558
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: