Provider Demographics
NPI:1003257981
Name:HARTENBERGER, GALEN DETRIK (DDS)
Entity Type:Individual
Prefix:DR
First Name:GALEN
Middle Name:DETRIK
Last Name:HARTENBERGER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 HOMESTEADS RD
Mailing Address - Street 2:
Mailing Address - City:PLACITAS
Mailing Address - State:NM
Mailing Address - Zip Code:87043-9230
Mailing Address - Country:US
Mailing Address - Phone:505-331-3517
Mailing Address - Fax:
Practice Address - Street 1:200 MANZANARES AVE E
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-4215
Practice Address - Country:US
Practice Address - Phone:575-835-3662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD39091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice