Basic Information
| Provider Information | |||||||||
| NPI: | 1861580276 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOODS | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | RUTH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MONTOYA | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | WOODS | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DMD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 130 | ||||||||
| Address2: | ACL INDIAN HOSP (IHS) ATTN BUSINESS OFFICE | ||||||||
| City: | SAN FIDEL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055526644 | ||||||||
| FaxNumber: | 5055525490 | ||||||||
| Practice Location | |||||||||
| Address1: | STATE RD 124 | ||||||||
| Address2: | LAGUNA DENTAL CLINIC | ||||||||
| City: | NEW LAGUNA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055526645 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 09/07/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DD2105 | NM | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | H3451 | 05 | NM | MEDICAID |