=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003257981
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GALEN DETRIK HARTENBERGER DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2013
-----------------------------------------------------
Last Update Date | 07/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 MANZANARES AVE E
-----------------------------------------------------
City | SOCORRO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87801-4215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-835-3662
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 HOMESTEADS RD
-----------------------------------------------------
City | PLACITAS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87043-9230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-331-3517
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DD3909
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------