Healthcare Provider Details

I. General information

NPI: 1619170339
Provider Name (Legal Business Name): AYANA E BLAGROVE RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

ROUTE 301 NORTH B STREET
ZUNI NM
87327-0467
US

IV. Provider business mailing address

PO BOX 1087
ZUNI NM
87327-1087
US

V. Phone/Fax

Practice location:
  • Phone: 505-782-4431
  • Fax:
Mailing address:
  • Phone: 505-782-7349
  • Fax: 505-782-7405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH010012L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: