Healthcare Provider Details

I. General information

NPI: 1003532599
Provider Name (Legal Business Name): DENTA DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2022
Last Update Date: 10/17/2022
Certification Date: 10/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3313 N GRIMES ST
HOBBS NM
88240-1219
US

IV. Provider business mailing address

3313 N GRIMES ST
HOBBS NM
88240-1219
US

V. Phone/Fax

Practice location:
  • Phone: 575-392-4290
  • Fax: 575-392-1982
Mailing address:
  • Phone: 575-392-4290
  • Fax: 575-392-1982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: LOI TA
Title or Position: PRESIDENT
Credential: DDS
Phone: 901-606-2355