Healthcare Provider Details

I. General information

NPI: 1346456514
Provider Name (Legal Business Name): BRIGHT STAR DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 E LOHMAN AVE SUITE 121
LAS CRUCES NM
88001-3167
US

IV. Provider business mailing address

2001 E LOHMAN AVE SUITE 121
LAS CRUCES NM
88001-3167
US

V. Phone/Fax

Practice location:
  • Phone: 505-526-4334
  • Fax: 505-526-7863
Mailing address:
  • Phone: 505-526-4334
  • Fax: 505-526-7863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1674
License Number StateNM

VIII. Authorized Official

Name: DR. BRIAN J GILBERT
Title or Position: CEO
Credential: D.D.S.
Phone: 505-526-4334