1083828453 NPI number — MS. EDWINA FAYE LEE DENTAL HYGIENIST

Table of content: MS. EDWINA FAYE LEE DENTAL HYGIENIST (NPI 1083828453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083828453 NPI number — MS. EDWINA FAYE LEE DENTAL HYGIENIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
EDWINA
Provider Middle Name:
FAYE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
DENTAL HYGIENIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HORN
Provider Other First Name:
EDWINA
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DENTAL HYGIENIST
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083828453
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 130
Provider Second Line Business Mailing Address:
ACOMA CANONCITO LAGUNA INDIAN HOSPITAL DHHS IHS
Provider Business Mailing Address City Name:
SAN FIDEL
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87049-0130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-552-5385
Provider Business Mailing Address Fax Number:
505-552-5473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
EXIT 102 OFF I40
Provider Second Line Business Practice Location Address:
1/2 MI SOUTH
Provider Business Practice Location Address City Name:
SAN FIDEL
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-552-5310
Provider Business Practice Location Address Fax Number:
505-552-5490
Provider Enumeration Date:
05/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 124Q00000X , with the licence number:  2038 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: H3451 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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