Provider Demographics
NPI:1386810331
Name:POLICARPIO, MYRNA L (DDS)
Entity type:Individual
Prefix:
First Name:MYRNA
Middle Name:L
Last Name:POLICARPIO
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:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:HATCH
Mailing Address - State:NM
Mailing Address - Zip Code:87937-0370
Mailing Address - Country:US
Mailing Address - Phone:575-267-3280
Mailing Address - Fax:575-267-1747
Practice Address - Street 1:1960 N DATE ST
Practice Address - Street 2:
Practice Address - City:T OR C
Practice Address - State:NM
Practice Address - Zip Code:87901-3701
Practice Address - Country:US
Practice Address - Phone:575-894-7662
Practice Address - Fax:575-894-7930
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD29841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice