Healthcare Provider Details

I. General information

NPI: 1114015526
Provider Name (Legal Business Name): ALAN FILIP TATZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 02/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ALOMA CANONCITO LAGUNA HOSTITAL IHS
SAN FIDEL NM
87049
US

IV. Provider business mailing address

ACL BUS OFFICE PO BOX 130
SAN FIDEL NM
87049
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-5310
  • Fax:
Mailing address:
  • Phone: 505-552-5310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number01916156
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: