Provider Demographics
NPI:1346802188
Name:ANGEL FIRE DENTAL CORP
Entity Type:Organization
Organization Name:ANGEL FIRE DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:DOOLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:575-214-4369
Mailing Address - Street 1:PO BOX 1953
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-1953
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27479 HWY 64
Practice Address - Street 2:
Practice Address - City:ANGEL FIRE
Practice Address - State:NM
Practice Address - Zip Code:87710
Practice Address - Country:US
Practice Address - Phone:575-214-4369
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental