Provider Demographics
NPI:1912036013
Name:ALPANO, ELLEN FAYE CAMPOMANES (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELLEN FAYE
Middle Name:CAMPOMANES
Last Name:ALPANO
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:PO BOX 4000
Mailing Address - Street 2:
Mailing Address - City:POLACCA
Mailing Address - State:AZ
Mailing Address - Zip Code:86042-4000
Mailing Address - Country:US
Mailing Address - Phone:928-737-6162
Mailing Address - Fax:928-737-6168
Practice Address - Street 1:HIGHWAY 264 MILEPOST 388
Practice Address - Street 2:
Practice Address - City:POLACCA
Practice Address - State:AZ
Practice Address - Zip Code:86042
Practice Address - Country:US
Practice Address - Phone:928-737-6167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13745122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ955031Medicaid