Healthcare Provider Details

I. General information

NPI: 1205828233
Provider Name (Legal Business Name): MICHAEL DENNIS HERRERA O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 01/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 GALISTEO ST. STE. G5 GALISTEO CENTER
SANTA FE NM
87505-2164
US

IV. Provider business mailing address

2019 GALISTEO ST. STE. G5 GALISTEO CENTER
SANTA FE NM
87505-2164
US

V. Phone/Fax

Practice location:
  • Phone: 505-989-9600
  • Fax: 505-982-3616
Mailing address:
  • Phone: 505-989-9600
  • Fax: 505-982-3616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number242
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: