Provider Demographics
NPI:1669696951
Name:TULAROSA BASIN DERMATOLOGY
Entity type:Organization
Organization Name:TULAROSA BASIN DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:TONCRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:505-437-6700
Mailing Address - Street 1:1212 9TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-5842
Mailing Address - Country:US
Mailing Address - Phone:505-437-6700
Mailing Address - Fax:505-437-6644
Practice Address - Street 1:1212 9TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-5842
Practice Address - Country:US
Practice Address - Phone:505-437-6700
Practice Address - Fax:505-437-6644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA115701174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty