Healthcare Provider Details

I. General information

NPI: 1386606929
Provider Name (Legal Business Name): DALE POTTER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROUTE 301 NORTH B STREET US INDIAN HEALTH SERVICES
ZUNI NM
87327-0467
US

IV. Provider business mailing address

PO BOX 467
ZUNI NM
87327-0467
US

V. Phone/Fax

Practice location:
  • Phone: 505-782-4431
  • Fax: 505-782-7327
Mailing address:
  • Phone: 505-782-4431
  • Fax: 505-782-7327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number16851
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: