Healthcare Provider Details

I. General information

NPI: 1285091181
Provider Name (Legal Business Name): SOUTHERN NEW MEXICO ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2016
Last Update Date: 01/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 E PINE ST STE B
DEMING NM
88030-7003
US

IV. Provider business mailing address

1310 E PINE ST STE B
DEMING NM
88030-7003
US

V. Phone/Fax

Practice location:
  • Phone: 575-544-9999
  • Fax: 575-546-1070
Mailing address:
  • Phone: 575-544-9999
  • Fax: 575-546-1070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD4435
License Number StateNM

VIII. Authorized Official

Name: EBONIE MARIE BOGDAN
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 505-892-9010