Healthcare Provider Details

I. General information

NPI: 1093261455
Provider Name (Legal Business Name): EASTERN NEW MEXICO ENDODONTICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 08/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W 21ST ST SUITE L1
CLOVIS NM
88101-4087
US

IV. Provider business mailing address

2000 W 21ST ST SUITE L1
CLOVIS NM
88101-4087
US

V. Phone/Fax

Practice location:
  • Phone: 575-762-8000
  • Fax: 575-763-0418
Mailing address:
  • Phone: 575-762-8000
  • Fax: 575-763-0418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. CHAD RICKY SOUTHARD
Title or Position: ADMINISTRATOR
Credential: FACHE, FHFMA
Phone: 806-797-4455