Healthcare Provider Details

I. General information

NPI: 1952145666
Provider Name (Legal Business Name): LEEANN NOLAN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2024
Last Update Date: 01/03/2025
Certification Date: 01/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3569 ZAFARANO DR
SANTA FE NM
87507-2618
US

IV. Provider business mailing address

309 DELGADO ST
SANTA FE NM
87501-2729
US

V. Phone/Fax

Practice location:
  • Phone: 505-986-8000
  • Fax:
Mailing address:
  • Phone: 973-908-5994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD012173
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD012173
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDB-2024-0400
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: