Provider Demographics
NPI:1154347201
Name:TRUJILL, EZLEN RONALD (DDS)
Entity type:Individual
Prefix:
First Name:EZLEN
Middle Name:RONALD
Last Name:TRUJILL
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 1:2050 BOTULPH RD.
Mailing Address - Street 2:SUITE C
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505
Mailing Address - Country:US
Mailing Address - Phone:505-983-7848
Mailing Address - Fax:505-983-6449
Practice Address - Street 1:2050 BOTULPH RD.
Practice Address - Street 2:SUITE C
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-983-7848
Practice Address - Fax:505-983-6449
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM18211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice