Provider Demographics
NPI:1316018039
Name:DR CLAY N COLEMAN
Entity Type:Organization
Organization Name:DR CLAY N COLEMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:NOYES
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:505-758-9338
Mailing Address - Street 1:PO BOX 517
Mailing Address - Street 2:
Mailing Address - City:RANCHOS DE TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87557-0517
Mailing Address - Country:US
Mailing Address - Phone:505-758-9338
Mailing Address - Fax:505-758-0705
Practice Address - Street 1:104 CRUZ ALTA RD
Practice Address - Street 2:SUITE FE
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571
Practice Address - Country:US
Practice Address - Phone:505-758-9338
Practice Address - Fax:505-758-0705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1229122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty