Healthcare Provider Details

I. General information

NPI: 1154039626
Provider Name (Legal Business Name): CARLOS VALLEJO SEDILLO RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2022
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 CEDAR ROAD
SAN FELIPE PUEBLO NM
87001
US

IV. Provider business mailing address

P.O. BOX 4342
SAN FELIPE PUEBLO NM
87001
US

V. Phone/Fax

Practice location:
  • Phone: 505-867-5025
  • Fax: 505-771-9998
Mailing address:
  • Phone: 505-867-5025
  • Fax: 505-771-9998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH4264
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: