Healthcare Provider Details

I. General information

NPI: 1871902593
Provider Name (Legal Business Name): SUNDANCE ORTHODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3903 BECKLAND DR
FARMINGTON NM
87402-4701
US

IV. Provider business mailing address

6588 E MAIN ST
FARMINGTON NM
87402-5122
US

V. Phone/Fax

Practice location:
  • Phone: 505-436-2727
  • Fax: 505-326-6800
Mailing address:
  • Phone: 505-326-6800
  • Fax: 505-326-6800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD2287
License Number StateNM

VIII. Authorized Official

Name: LISA HODGES
Title or Position: OPERATIONS DIRECTOR
Credential:
Phone: 505-787-2965