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General NPI Number Information
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NPI Number | 1639361371
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Entity Type | Organization
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Legal Business Name | SMALL FRY DENTISTRY PC
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Dates
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Enumeration Date | 08/16/2007
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Last Update Date | 08/16/2007
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Provider Practice Location Address
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Address Line | 1401 LINDA DR
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City | GALLUP
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State | NM
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Zip | 87301-5615
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Country | US
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Telephone | 505-870-6128
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Fax |
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Provider Business Mailing Address
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Address Line | 1401 LINDA DR
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City | GALLUP
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State | NM
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Zip | 87301-5615
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. EDUARDO VALDA
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Credential | DDS
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Telephone | 505-870-6128
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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 | DD2150
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License Number State | NM
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