Healthcare Provider Details

I. General information

NPI: 1023344181
Provider Name (Legal Business Name): SUNDANCE DENTAL CARE OF BLOOMFIELD, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2009
Last Update Date: 05/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SOUTH FIRST STREET
BLOOMFIELD NM
87413
US

IV. Provider business mailing address

6588 E MAIN ST
FARMINGTON NM
87402-5122
US

V. Phone/Fax

Practice location:
  • Phone: 505-632-3344
  • Fax:
Mailing address:
  • Phone: 505-326-6800
  • Fax: 505-326-6820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD2287
License Number StateNM

VIII. Authorized Official

Name: DR. MICHAEL TORNOW
Title or Position: DENTIST/OWNER
Credential:
Phone: 505-326-6800