=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225158348
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PUEBLO OF ISLETA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2007
-----------------------------------------------------
Last Update Date | 05/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 01 SAGEBRUSH RD
-----------------------------------------------------
City | ISLETA
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87022-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-869-4863
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 01 SAGEBRUSH RD
-----------------------------------------------------
City | ISLETA
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87022-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-869-4863
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. VOLELLE K ZAMORA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 505-869-4094
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223D0001X
-----------------------------------------------------
Taxonomy Name | Public Health Dentistry
-----------------------------------------------------
License Number | 501C
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------