Provider Demographics
NPI:1457793416
Name:DETRIK, DAVINA ROSE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVINA
Middle Name:ROSE
Last Name:DETRIK
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 1:6835 GUADALUPE TRL NW
Mailing Address - Street 2:
Mailing Address - City:LOS RANCHOS
Mailing Address - State:NM
Mailing Address - Zip Code:87107-6205
Mailing Address - Country:US
Mailing Address - Phone:303-519-3454
Mailing Address - Fax:303-519-3454
Practice Address - Street 1:2 CALLE MEDICO STE 3
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4785
Practice Address - Country:US
Practice Address - Phone:505-303-1974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2024-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD3923122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist