MEDICARE: LEEANN NOLAN DMD

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	122300000X	Dentist	D012173	AZ
2	1223G0001X	General Practice Dentistry	D012173	AZ
3	1223G0001X	General Practice Dentistry	DB-2024-0400	NM

General Provider Information

NPI Number	:	1952145666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEEANN NOLAN DMD

Provider Business Mailing Address
First Line	:	309 DELGADO ST
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87501-2729
Country	:	US
Telephone Number	:	973-908-5994
Fax Number	:

Provider Business Practice Location Address
First Line	:	3569 ZAFARANO DR
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87507-2618
Country	:	US
Telephone Number	:	505-986-8000
Fax Number	:

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

Provider Enumeration Date	:	06/19/2024
Last Update Date	:	01/03/2025

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