Healthcare Provider Details

I. General information

NPI: 1114216389
Provider Name (Legal Business Name): LAS CRUCES DENTAL SOLUTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2011
Last Update Date: 03/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 E LOHMAN AVE STE 121
LAS CRUCES NM
88001-3195
US

IV. Provider business mailing address

2001 E LOHMAN AVE STE 121
LAS CRUCES NM
88001-3195
US

V. Phone/Fax

Practice location:
  • Phone: 575-541-0084
  • Fax: 575-541-0087
Mailing address:
  • Phone: 575-541-0084
  • Fax: 575-541-0087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD3330
License Number StateCO

VIII. Authorized Official

Name: MATTHEW PETERSON
Title or Position: OWNER
Credential: DDS
Phone: 575-541-0084