Provider Demographics
NPI:1891776225
Name:VALDIVIA, PATRICIA B (DDS)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:B
Last Name:VALDIVIA
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 1:1209 BONITA ST
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-2103
Mailing Address - Country:US
Mailing Address - Phone:505-285-6937
Mailing Address - Fax:
Practice Address - Street 1:1209 BONITA ST
Practice Address - Street 2:
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2103
Practice Address - Country:US
Practice Address - Phone:505-876-4034
Practice Address - Fax:505-876-4036
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD16371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM89292Medicaid
NM837938OtherUNITED CONCOORDIA
NM6583OtherDORAL DENTAL