Provider Demographics
NPI:1730101726
Name:SAN JUAN BASIN HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:SAN JUAN BASIN HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOLLON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:970-247-5702
Mailing Address - Street 1:281 SAWYER DR.
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81303-3409
Mailing Address - Country:US
Mailing Address - Phone:970-247-5702
Mailing Address - Fax:970-247-9126
Practice Address - Street 1:701 CAMINO DEL RIO
Practice Address - Street 2:SOUTHWEST SMILE MAKERS
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301
Practice Address - Country:US
Practice Address - Phone:970-385-4480
Practice Address - Fax:970-247-7882
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAN JUAN BASIN HEALTH DEPARTMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-25
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO96635339Medicaid