Healthcare Provider Details

I. General information

NPI: 1922983444
Provider Name (Legal Business Name): DENISE KIKLIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2025
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 W HIGHWAY 22
SANTO DOMINGO PUEBLO NM
87052-1283
US

IV. Provider business mailing address

PO BOX 340
SANTO DOMINGO PUEBLO NM
87052-0340
US

V. Phone/Fax

Practice location:
  • Phone: 505-465-3060
  • Fax: 505-318-1079
Mailing address:
  • Phone: 505-465-3060
  • Fax: 505-318-1078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberNDP-2024-0101
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: