Healthcare Provider Details

I. General information

NPI: 1043233430
Provider Name (Legal Business Name): LAS CRUCES DENTAL ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 11/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2569 E IDAHO AVE # A
LAS CRUCES NM
88011-4578
US

IV. Provider business mailing address

2569 E IDAHO AVE # A
LAS CRUCES NM
88011-4578
US

V. Phone/Fax

Practice location:
  • Phone: 575-523-1479
  • Fax: 575-523-2974
Mailing address:
  • Phone: 575-523-1479
  • Fax: 575-523-2974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MARIO J. SAMANIEGO
Title or Position: OWNER
Credential: DDS
Phone: 575-523-1479