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General NPI Number Information
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NPI Number | 1457793416
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Entity Type | Individual
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Provider Name | DAVINA ROSE DETRIK DDS
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Gender | Female
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Dates
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Enumeration Date | 07/19/2013
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Last Update Date | 02/10/2024
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Provider Practice Location Address
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Address Line | 2 CALLE MEDICO STE 3
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City | SANTA FE
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State | NM
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Zip | 87505-4785
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Country | US
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Telephone | 505-303-1974
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Fax |
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Provider Business Mailing Address
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Address Line | 6835 GUADALUPE TRL NW
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City | LOS RANCHOS
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State | NM
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Zip | 87107-6205
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Country | US
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Telephone | 303-519-3454
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Fax | 303-519-3454
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | DD3923
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License Number State | NM
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