MEDICARE: FAMILIA DENTAL LAS CRUCES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1144513508
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILIA DENTAL LAS CRUCES LLC

Provider Business Mailing Address
First Line	:	2050 E ALGONQUIN RD
Second Line	:	SUITE 610
City	:	SCHAUMBURG
State	:	IL
Zip	:	60173-4189
Country	:	US
Telephone Number	:	847-453-7396
Fax Number	:	847-453-7396

Provider Business Practice Location Address
First Line	:	1025 EL PASEO RD
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88001-6029
Country	:	US
Telephone Number	:	888-988-4066
Fax Number	:	847-496-7603

Authorized Official
Title or Position	:	CREDENTIALING & PAYER RELATIONS MGR
Name	:	MR. BRANDON ALEXANDER TAYLOR
Credential	:	CPCS
Telephone Number	:	847-453-7396

Provider Enumeration Date	:	05/18/2011
Last Update Date	:	10/15/2021

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