Basic Information
| Provider Information | |||||||||
| NPI: | 1104991538 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCQUITTY | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | J | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810033111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195831800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2008 SAINT MICHAELS DR | ||||||||
| Address2: | #B | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057682 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054744993 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DD2364 | NM | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 51424061 | 05 | NM | MEDICAID | 0018257 | 01 | NM | DORAL | OTHER | 1771969 | 01 | NM | UNITED CONCORDIA | OTHER |