Healthcare Provider Details

I. General information

NPI: 1619666732
Provider Name (Legal Business Name): ANIMAS PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2023
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 E PINON FRONTAGE RD BLDG 200
FARMINGTON NM
87402-5084
US

IV. Provider business mailing address

2650 E PINON FRONTAGE RD BLDG 200
FARMINGTON NM
87402-5084
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JENS WILSON
Title or Position: PEDIATRIC DENTIST
Credential: DMD
Phone: 435-459-4457