Provider Demographics
NPI:1245500479
Name:MUKES, VISANIO ELARRYO (DDS)
Entity type:Individual
Prefix:DR
First Name:VISANIO
Middle Name:ELARRYO
Last Name:MUKES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 CERRILLOS RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-3026
Mailing Address - Country:US
Mailing Address - Phone:505-946-9485
Mailing Address - Fax:
Practice Address - Street 1:1700 CERRILLOS RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-3026
Practice Address - Country:US
Practice Address - Phone:505-946-9485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-04
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15189122300000X
VA0401413408122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist