MEDICARE: UNIVERSITY FAMILY DENTAL PC

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	122300000X	Dentist	2498	NM
2	122300000X	Dentist	2317	NM

General Provider Information

NPI Number	:	1396174116
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY FAMILY DENTAL PC

Provider Business Mailing Address
First Line	:	705 E UNIVERSITY AVE STE B
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88001-5637
Country	:	US
Telephone Number	:	575-521-0127
Fax Number	:	575-647-9533

Provider Business Practice Location Address
First Line	:	705 E UNIVERSITY AVE STE B
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88001-5637
Country	:	US
Telephone Number	:	575-521-0127
Fax Number	:	575-647-9533

Authorized Official
Title or Position	:	DENTIST
Name	:	KIMBERLY H MARTIN
Credential	:	DMD
Telephone Number	:	575-521-0127

Provider Enumeration Date	:	11/02/2013
Last Update Date	:	11/02/2013

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