MEDICARE: SOUTWEST FAMILY DENTAL, 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	122300000X	Dentist	DD2601	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699940742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTWEST FAMILY DENTAL, LLC

Provider Business Mailing Address
First Line	:	301 E LOHMAN AVE
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88001-3667
Country	:	US
Telephone Number	:	575-524-4900
Fax Number	:	575-524-8300

Provider Business Practice Location Address
First Line	:	301 E LOHMAN AVE
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88001-3667
Country	:	US
Telephone Number	:	575-524-4900
Fax Number	:	575-524-8300

Authorized Official
Title or Position	:	OWNER
Name	:	DR. HARVEY S REITER
Credential	:	D.D.S
Telephone Number	:	575-541-0072

Provider Enumeration Date	:	04/29/2008
Last Update Date	:	04/29/2008

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