Provider Demographics
NPI:1871586248
Name:ST. LOUIS, LYN M (DH)
Entity type:Individual
Prefix:MS
First Name:LYN
Middle Name:M
Last Name:ST. LOUIS
Suffix:
Gender:F
Credentials:DH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N RAILROAD AVE
Mailing Address - Street 2:P.O. BOX 158
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2627
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:505-753-5815
Practice Address - Street 1:HOUSE#013405 STATE RD. 75 - HCNNM PENASCO DENTAL
Practice Address - Street 2:
Practice Address - City:PENASCO
Practice Address - State:NM
Practice Address - Zip Code:87553
Practice Address - Country:US
Practice Address - Phone:505-587-2809
Practice Address - Fax:505-587-1944
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH2558124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM9177772OtherDORAL
NM81334397Medicaid