Healthcare Provider Details

I. General information

NPI: 1679017453
Provider Name (Legal Business Name): EMBUDO DENTAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2016
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 STATE HIGHWAY 68
EMBUDO NM
87531-0037
US

IV. Provider business mailing address

PO BOX 37 1102 STATE HIGHWAY 68
EMBUDO NM
87531-0037
US

V. Phone/Fax

Practice location:
  • Phone: 505-579-4680
  • Fax: 505-579-4074
Mailing address:
  • Phone: 505-579-4680
  • Fax: 505-579-4074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDD1074
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDD1953
License Number StateNM

VIII. Authorized Official

Name: KELLIE A HARRIS
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 505-579-4680