1558436261 NPI number — DHHS PHS IHS ACL LAGUNA DENTAL CLINIC

Table of content: (NPI 1558436261)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558436261 NPI number — DHHS PHS IHS ACL LAGUNA DENTAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DHHS PHS IHS ACL LAGUNA DENTAL CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558436261
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
ACOMA CANONCITO LAGUNA INDIAN HOSPITAL
Provider Second Line Business Mailing Address:
PO BOX 130
Provider Business Mailing Address City Name:
SAN FIDEL
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-552-5385
Provider Business Mailing Address Fax Number:
505-552-5490

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
STATE RD #124 EXIT 108 OFF I-40 3 MI NORTH
Provider Second Line Business Practice Location Address:
LAGUNA DENTAL CLINIC
Provider Business Practice Location Address City Name:
NEW LAGUNA
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-552-6645
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
THORNE
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
R
Authorized Official Title or Position:
ACL IHS CEO
Authorized Official Telephone Number:
505-552-5301

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; 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".




Copyright © 2007-2025 www.npivalidator.com