Provider Demographics
NPI:1104435130
Name:DE TABOADA DA SILVA, ATENAS (DMD)
Entity type:Individual
Prefix:
First Name:ATENAS
Middle Name:
Last Name:DE TABOADA DA SILVA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 AIRPORT DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-2602
Mailing Address - Country:US
Mailing Address - Phone:954-225-7647
Mailing Address - Fax:
Practice Address - Street 1:506 AIRPORT DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2602
Practice Address - Country:US
Practice Address - Phone:505-325-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-27
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD5295.1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice