Healthcare Provider Details

I. General information

NPI: 1457793416
Provider Name (Legal Business Name): DAVINA ROSE DETRIK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2013
Last Update Date: 02/10/2024
Certification Date: 02/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 CALLE MEDICO STE 3
SANTA FE NM
87505-4785
US

IV. Provider business mailing address

6835 GUADALUPE TRL NW
LOS RANCHOS NM
87107-6205
US

V. Phone/Fax

Practice location:
  • Phone: 505-303-1974
  • Fax:
Mailing address:
  • Phone: 303-519-3454
  • Fax: 303-519-3454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD3923
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: