Provider Demographics
NPI:1558436261
Name:DHHS PHS IHS ACL LAGUNA DENTAL CLINIC
Entity Type:Organization
Organization Name:DHHS PHS IHS ACL LAGUNA DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACL IHS CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:THORNE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:505-552-5301
Mailing Address - Street 1:ACOMA CANONCITO LAGUNA INDIAN HOSPITAL
Mailing Address - Street 2:PO BOX 130
Mailing Address - City:SAN FIDEL
Mailing Address - State:NM
Mailing Address - Zip Code:87049
Mailing Address - Country:US
Mailing Address - Phone:505-552-5385
Mailing Address - Fax:505-552-5490
Practice Address - Street 1:STATE RD #124 EXIT 108 OFF I-40 3 MI NORTH
Practice Address - Street 2:LAGUNA DENTAL CLINIC
Practice Address - City:NEW LAGUNA
Practice Address - State:NM
Practice Address - Zip Code:87038
Practice Address - Country:US
Practice Address - Phone:505-552-6645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH3451Medicaid
NMH3451Medicaid
PHS000Medicare UPIN