Healthcare Provider Details

I. General information

NPI: 1992904288
Provider Name (Legal Business Name): DIVINE DENTAL OF SANTA FE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2007
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 SAINT MICHAELS DR STE B
SANTA FE NM
87505-7610
US

IV. Provider business mailing address

550 SAINT MICHAELS DR STE B
SANTA FE NM
87505-7610
US

V. Phone/Fax

Practice location:
  • Phone: 505-471-7000
  • Fax:
Mailing address:
  • Phone: 505-471-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2351
License Number StateNM

VIII. Authorized Official

Name: DR. ESMAEL R VALDEZ
Title or Position: CO-OWNER
Credential: D.D.S
Phone: 505-454-8483