Provider Demographics
NPI:1770849796
Name:QUAM, ZELLISHA ALEXIS (DMD)
Entity Type:Individual
Prefix:
First Name:ZELLISHA
Middle Name:ALEXIS
Last Name:QUAM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5928 NIGHT SHADOW AVE NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-1975
Mailing Address - Country:US
Mailing Address - Phone:505-862-2467
Mailing Address - Fax:
Practice Address - Street 1:9169 COORS BLVD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-3101
Practice Address - Country:US
Practice Address - Phone:505-346-2306
Practice Address - Fax:505-346-2311
Is Sole Proprietor?:No
Enumeration Date:2012-04-03
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD3884122300000X, 1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223D0001XDental ProvidersDentistDental Public Health