Provider Demographics
NPI:1699299693
Name:MACALTAO, ALFRED MATTHEW
Entity type:Individual
Prefix:
First Name:ALFRED
Middle Name:MATTHEW
Last Name:MACALTAO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 N SAN MATEO DR APT 107
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-2804
Mailing Address - Country:US
Mailing Address - Phone:917-697-1269
Mailing Address - Fax:
Practice Address - Street 1:JUNCTION OF HIGHWAY 371 NAVAJO ROUTE 9
Practice Address - Street 2:
Practice Address - City:CROWNPOINT
Practice Address - State:NM
Practice Address - Zip Code:87313-0358
Practice Address - Country:US
Practice Address - Phone:505-786-5291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2017-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025404124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist