Provider Demographics
NPI:1508970997
Name:LESLIE-PUHUYAOMA, KATRINA J (DDS)
Entity Type:Individual
Prefix:DR
First Name:KATRINA
Middle Name:J
Last Name:LESLIE-PUHUYAOMA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:KATRINA
Other - Middle Name:J
Other - Last Name:LESLIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-0160
Mailing Address - Country:US
Mailing Address - Phone:505-368-6001
Mailing Address - Fax:505-368-6360
Practice Address - Street 1:US HWY 491 NORTH
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420
Practice Address - Country:US
Practice Address - Phone:505-368-6001
Practice Address - Fax:505-368-6360
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD4647122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ571019Medicaid
NM97577855Medicaid
CO10720022Medicaid