Healthcare Provider Details

I. General information

NPI: 1679108815
Provider Name (Legal Business Name): BELEN FAMILY DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2020
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 E RIVER RD
BELEN NM
87002-7429
US

IV. Provider business mailing address

1501 E RIVER RD
BELEN NM
87002-7429
US

V. Phone/Fax

Practice location:
  • Phone: 505-864-6969
  • Fax: 505-864-9310
Mailing address:
  • Phone: 505-864-6969
  • Fax: 505-864-9310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. JAYSON GARCIA-GURULE
Title or Position: GENERAL DENTIST
Credential: DDS
Phone: 505-615-2999