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General NPI Number Information
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NPI Number | 1992904288
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Entity Type | Organization
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Legal Business Name | DIVINE DENTAL OF SANTA FE
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Dates
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Enumeration Date | 07/16/2007
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Last Update Date | 07/16/2007
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Provider Practice Location Address
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Address Line | 550 SAINT MICHAELS DR STE B
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City | SANTA FE
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State | NM
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Zip | 87505-7610
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Country | US
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Telephone | 505-471-7000
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Fax |
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Provider Business Mailing Address
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Address Line | 550 SAINT MICHAELS DR STE B
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City | SANTA FE
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State | NM
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Zip | 87505-7610
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Country | US
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Telephone | 505-471-7000
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Fax |
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Authorized Official
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Title or Position | CO-OWNER
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Name | DR. ESMAEL R VALDEZ
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Credential | D.D.S
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Telephone | 505-454-8483
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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 | DD2351
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License Number State | NM
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