Healthcare Provider Details

I. General information

NPI: 1265177679
Provider Name (Legal Business Name): NEON KIDS DENTAL OF CORTEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2022
Last Update Date: 04/29/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S MAPLE ST STE 1
CORTEZ CO
81321-3563
US

IV. Provider business mailing address

4760 N BUTLER AVE STE B
FARMINGTON NM
87401-0816
US

V. Phone/Fax

Practice location:
  • Phone: 505-592-0482
  • Fax:
Mailing address:
  • Phone: 505-592-0482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: AMANDA SALAZAR
Title or Position: BILLING
Credential:
Phone: 505-592-0482