Healthcare Provider Details

I. General information

NPI: 1295823177
Provider Name (Legal Business Name): ANIMAS PEDIATRIC DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 11/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 E PINON FRONTAGE RD. BLDG. 200
FARMINGTON NM
87402-5061
US

IV. Provider business mailing address

2650 E PINON FRONTAGE RD. BLDG. 200
FARMINGTON NM
87402-5061
US

V. Phone/Fax

Practice location:
  • Phone: 505-599-9359
  • Fax: 505-599-8177
Mailing address:
  • Phone: 505-599-9359
  • Fax: 505-599-8177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDD1997
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD1997
License Number StateNM

VIII. Authorized Official

Name: LAWRENCE SUAZO
Title or Position: OWNER
Credential: D.D.S
Phone: 505-599-9359