=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417699612
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CELES BARBONE RDH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2022
-----------------------------------------------------
Last Update Date | 04/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1748 W MALONEY AVE
-----------------------------------------------------
City | GALLUP
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87301-3333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-863-8100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2071
-----------------------------------------------------
City | CROWNPOINT
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87313-2071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-320-2263
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | DH4434
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------