Healthcare Provider Details

I. General information

NPI: 1497033310
Provider Name (Legal Business Name): LAS CRUCES DENTAL ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2011
Last Update Date: 04/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1022 9TH ST
ALAMOGORDO NM
88310-6470
US

IV. Provider business mailing address

1022 9TH ST
ALAMOGORDO NM
88310-6470
US

V. Phone/Fax

Practice location:
  • Phone: 575-437-7473
  • Fax: 575-437-0079
Mailing address:
  • Phone: 575-437-7473
  • Fax: 575-437-0079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MR. MARIO SAMANIEGO
Title or Position: PRESIDENT
Credential: DDS
Phone: 575-437-7473