Healthcare Provider Details

I. General information

NPI: 1104170331
Provider Name (Legal Business Name): CLAUDIO CAYCEDO DDS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2012
Last Update Date: 11/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 W CLINTON ST
HOBBS NM
88240-8201
US

IV. Provider business mailing address

111 W CLINTON ST
HOBBS NM
88240-8201
US

V. Phone/Fax

Practice location:
  • Phone: 575-393-6047
  • Fax:
Mailing address:
  • Phone: 575-393-6047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD2385
License Number StateNM

VIII. Authorized Official

Name: CLAUDIO CAYCEDO
Title or Position: OWNER
Credential: D.D.S.
Phone: 214-794-1504