Healthcare Provider Details

I. General information

NPI: 1114692209
Provider Name (Legal Business Name): SMILE DOCTORS OF NEW MEXICO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2021
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 W JOE HARVEY BLVD
HOBBS NM
88240-0907
US

IV. Provider business mailing address

PO BOX 674456
DALLAS TX
75267-4456
US

V. Phone/Fax

Practice location:
  • Phone: 806-794-8124
  • Fax:
Mailing address:
  • Phone: 806-794-8124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GREGORY GOGGANS
Title or Position: PRESIDENT
Credential: DMD
Phone: 806-794-8124