MEDICARE: DR. VESNA DELIC DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DD2386	NM

General Provider Information

NPI Number	:	1336140169
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VESNA DELIC DDS

Provider Business Mailing Address
First Line	:	9020 VILLAGE AVE NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87122-2601
Country	:	US
Telephone Number	:	505-797-4433
Fax Number	:

Provider Business Practice Location Address
First Line	:	1924 JUAN TABO BLVD NE
Second Line	:	SUITE C
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-3358
Country	:	US
Telephone Number	:	505-293-3451
Fax Number	:	505-293-0027

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/02/2005
Last Update Date	:	07/08/2007

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