Provider Demographics
NPI:1700862117
Name:VALDA, AMALIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMALIA
Middle Name:
Last Name:VALDA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 LINDA DR
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5615
Mailing Address - Country:US
Mailing Address - Phone:505-870-6128
Mailing Address - Fax:
Practice Address - Street 1:107 W GREEN ST
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-6241
Practice Address - Country:US
Practice Address - Phone:505-870-6128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD21591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMA5642Medicaid