Healthcare Provider Details

I. General information

NPI: 1598143257
Provider Name (Legal Business Name): DEMING ORTHODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2015
Last Update Date: 05/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 S GOLD AVE
DEMING NM
88030-4161
US

IV. Provider business mailing address

710 S GOLD AVE
DEMING NM
88030-4161
US

V. Phone/Fax

Practice location:
  • Phone: 303-887-4400
  • Fax:
Mailing address:
  • Phone: 303-887-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD4015
License Number StateNM

VIII. Authorized Official

Name: ROBERT E. BREWKA
Title or Position: OWNER/ORTHODONTIST
Credential: DDS
Phone: 303-887-4400