Healthcare Provider Details

I. General information

NPI: 1174956676
Provider Name (Legal Business Name): SOUTHERN NEW MEXICO DENTAL GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2013
Last Update Date: 11/20/2020
Certification Date: 11/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2455 S. TELSHOR
LAS CRUCES NM
88011
US

IV. Provider business mailing address

2455 S. TELSHOR
LAS CRUCES NM
88011
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-0454
  • Fax: 575-522-3472
Mailing address:
  • Phone: 575-522-0454
  • Fax: 575-522-3472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD3462
License Number StateNM

VIII. Authorized Official

Name: DR. ROBERTO BOBBY ESPINEZA
Title or Position: OWNER
Credential: DDS
Phone: 575-382-2054