Healthcare Provider Details

I. General information

NPI: 1437622503
Provider Name (Legal Business Name): NORTHRISE DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2019
Last Update Date: 01/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2540 N TELSHOR BLVD STE E
LAS CRUCES NM
88011-8201
US

IV. Provider business mailing address

2540 N TELSHOR BLVD STE E
LAS CRUCES NM
88011-8201
US

V. Phone/Fax

Practice location:
  • Phone: 575-521-9375
  • Fax: 575-521-2637
Mailing address:
  • Phone: 575-521-9375
  • Fax: 575-521-2637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JARED WALLIS
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 575-521-9375