Healthcare Provider Details

I. General information

NPI: 1831410745
Provider Name (Legal Business Name): NEW MEXICO SMILES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2010
Last Update Date: 06/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3812 BENJAMIN DAVIS DR
CLOVIS NM
88101-2721
US

IV. Provider business mailing address

3812 BENJAMIN DAVIS DR
CLOVIS NM
88101-2721
US

V. Phone/Fax

Practice location:
  • Phone: 575-218-3541
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD3014
License Number StateNM

VIII. Authorized Official

Name: DR. ADAM STRONG BUNKER
Title or Position: DENTIST
Credential: DMD
Phone: 575-218-3541