Healthcare Provider Details

I. General information

NPI: 1245599653
Provider Name (Legal Business Name): DIEGO ERNESTO HURTADO D.D.S., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2012
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 GALISTEO ST
SANTA FE NM
87505
US

IV. Provider business mailing address

2948 DURANGO DR
SANTA FE NM
87507-4886
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-0694
  • Fax:
Mailing address:
  • Phone: 505-250-1167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDD4927
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: