Healthcare Provider Details

I. General information

NPI: 1659387090
Provider Name (Legal Business Name): DESERT HILLS DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 E 30TH ST
FARMINGTON NM
87401-4503
US

IV. Provider business mailing address

2525 E 30TH ST
FARMINGTON NM
87401-4503
US

V. Phone/Fax

Practice location:
  • Phone: 505-327-4863
  • Fax: 505-327-5394
Mailing address:
  • Phone: 505-327-4863
  • Fax: 505-327-5394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1586
License Number StateNM

VIII. Authorized Official

Name: DR. CHARLES MELLEN SCHUMACHER
Title or Position: OWNER
Credential: D.D.S.
Phone: 505-327-4863