Healthcare Provider Details

I. General information

NPI: 1558666883
Provider Name (Legal Business Name): PLAINS DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2011
Last Update Date: 12/23/2019
Certification Date: 12/23/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 W LLANO ESTACADO BLVD
CLOVIS NM
88101
US

IV. Provider business mailing address

121 W LLANO ESTACADO BLVD
CLOVIS NM
88101
US

V. Phone/Fax

Practice location:
  • Phone: 575-742-3100
  • Fax: 575-742-3400
Mailing address:
  • Phone: 575-742-3100
  • Fax: 575-742-3400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD3395
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH1504
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH2245
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH2884
License Number StateNM
# 5
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberDA3975
License Number StateNM
# 6
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberDA2349
License Number StateNM
# 7
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD1887
License Number StateNM

VIII. Authorized Official

Name: MS. JULIE A O'QUINN
Title or Position: OWNER
Credential: D.D.S.
Phone: 575-742-3100