Provider Demographics
NPI:1225158348
Name:PUEBLO OF ISLETA
Entity Type:Organization
Organization Name:PUEBLO OF ISLETA
Other - Org Name:PUEBLO OF ISLETA DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:VOLELLE
Authorized Official - Middle Name:K
Authorized Official - Last Name:ZAMORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-869-4094
Mailing Address - Street 1:01 SAGEBRUSH RD
Mailing Address - Street 2:
Mailing Address - City:ISLETA
Mailing Address - State:NM
Mailing Address - Zip Code:87022-0000
Mailing Address - Country:US
Mailing Address - Phone:505-869-4863
Mailing Address - Fax:
Practice Address - Street 1:01 SAGEBRUSH RD
Practice Address - Street 2:
Practice Address - City:ISLETA
Practice Address - State:NM
Practice Address - Zip Code:87022-0000
Practice Address - Country:US
Practice Address - Phone:505-869-4863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM501C1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM55528309Medicaid