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General NPI Number Information
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NPI Number | 1679740013
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Entity Type | Organization
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Legal Business Name | SAN JUAN COLLEGE
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Dates
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Enumeration Date | 05/14/2008
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Last Update Date | 05/14/2008
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Provider Practice Location Address
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Address Line | 4601 COLLEGE BLVD DENTAL CLINIC
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City | FARMINGTON
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State | NM
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Zip | 87402-4609
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Country | US
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Telephone | 505-566-3126
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Fax | 505-566-3790
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Provider Business Mailing Address
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Address Line | 4601 COLLEGE BLVD
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City | FARMINGTON
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State | NM
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Zip | 87402-4609
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Country | US
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Telephone | 505-566-3126
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Fax | 505-566-3790
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CAROL SPENCER
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Credential |
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Telephone | 505-566-3209
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DD-2461
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License Number State | NM
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