Healthcare Provider Details

I. General information

NPI: 1184766552
Provider Name (Legal Business Name): CHILDREN'S DENTAL CLINIC OF LAS CRUCES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 CALLE DE NINOS
LAS CRUCES NM
88005-3293
US

IV. Provider business mailing address

1901 CALLE DE NINOS
LAS CRUCES NM
88005-3293
US

V. Phone/Fax

Practice location:
  • Phone: 719-671-5617
  • Fax:
Mailing address:
  • Phone: 719-671-5617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2445
License Number StateNM

VIII. Authorized Official

Name: DR. TODD M PARCO
Title or Position: OWNER
Credential: DDS
Phone: 505-526-5522