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General NPI Number Information
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NPI Number | 1073844221
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Entity Type | Organization
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Legal Business Name | DR. JACK SMALLEY D.D.S.
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Dates
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Enumeration Date | 01/27/2010
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Last Update Date | 01/27/2010
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Provider Practice Location Address
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Address Line | 1700 N BUTLER AVE
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City | FARMINGTON
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State | NM
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Zip | 87401-6331
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Country | US
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Telephone | 505-327-3331
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Fax | 505-327-0873
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Provider Business Mailing Address
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Address Line | 1700 N BUTLER AVE
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City | FARMINGTON
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State | NM
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Zip | 87401-6331
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Country | US
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Telephone | 505-327-3331
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Fax | 505-327-0873
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. DEANZA DAWN SONA
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Credential |
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Telephone | 505-327-3331
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 1918
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License Number State | NM
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