Healthcare Provider Details

I. General information

NPI: 1588750848
Provider Name (Legal Business Name): WILLIAM GEORGE MORNINGSTAR DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

I-40 EXIT 102 SOUTH 1/2 MI ACL INDIAN HOSPITAL
SAN FIDEL NM
87049
US

IV. Provider business mailing address

EXIT 102 I-40 SOUTH 1/2 MI ACL INDIAN HOSP IHS ATTN BUS OFFICE
SAN FIDEL NM
87049
US

V. Phone/Fax

Practice location:
  • Phone: 505-552-5310
  • Fax: 505-552-5490
Mailing address:
  • Phone: 505-552-5385
  • Fax: 505-552-5473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD1332
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: