=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346802188
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGEL FIRE DENTAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2019
-----------------------------------------------------
Last Update Date | 07/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27479 HWY 64
-----------------------------------------------------
City | ANGEL FIRE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-214-4369
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1953
-----------------------------------------------------
City | TAOS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87571-1953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | TIMOTHY DOOLIN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 575-214-4369
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------