Healthcare Provider Details

I. General information

NPI: 1386810331
Provider Name (Legal Business Name): MYRNA L POLICARPIO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 08/24/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1960 N DATE ST
T OR C NM
87901-3701
US

IV. Provider business mailing address

PO BOX 370
HATCH NM
87937-0370
US

V. Phone/Fax

Practice location:
  • Phone: 575-894-7662
  • Fax: 575-894-7930
Mailing address:
  • Phone: 575-267-3280
  • Fax: 575-267-1747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD2984
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: