Healthcare Provider Details

I. General information

NPI: 1366876419
Provider Name (Legal Business Name): CENTER FOR TMJ & SLEEP DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2013
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 S DON ROSER DR
LAS CRUCES NM
88011-4515
US

IV. Provider business mailing address

1423 S DON ROSER DR
LAS CRUCES NM
88011-4515
US

V. Phone/Fax

Practice location:
  • Phone: 575-541-0072
  • Fax: 575-541-1908
Mailing address:
  • Phone: 575-541-0072
  • Fax: 575-541-1908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberNM2601
License Number StateNM

VIII. Authorized Official

Name: MRS. EILEEN RAE AMBRIZ
Title or Position: CLINIC ADMINSTRATOR
Credential:
Phone: 575-541-0072