Healthcare Provider Details

I. General information

NPI: 1336505916
Provider Name (Legal Business Name): CLOVIS FAMILY DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2016
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W 21ST ST STE L1
CLOVIS NM
88101-1400
US

IV. Provider business mailing address

2000 W 21ST ST STE L1
CLOVIS NM
88101-1400
US

V. Phone/Fax

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

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: JULIE D BRIDGES
Title or Position: MEMBER
Credential:
Phone: 575-356-8514