Healthcare Provider Details

I. General information

NPI: 1154624401
Provider Name (Legal Business Name): PEDIATRIC DENTAL SPECIALIST OF NEW MEXICO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2010
Last Update Date: 12/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 SOUTH TELSHOR MEMORIAL MEDICAL HOSPITAL
LAS CRUCES NM
88011-7594
US

IV. Provider business mailing address

5475 REMINGTON ROAD DR. PETER HAYES
LAS CRUCES NM
88011-7594
US

V. Phone/Fax

Practice location:
  • Phone: 575-621-0800
  • Fax: 575-373-3091
Mailing address:
  • Phone: 575-621-0800
  • Fax: 575-373-3091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2233
License Number StateNM

VIII. Authorized Official

Name: DR. PETER ANDREW HAYES
Title or Position: PEDIATRIC DENTAL SPECIALIST
Credential: DMD, MS.
Phone: 575-621-0800