Healthcare Provider Details

I. General information

NPI: 1609832740
Provider Name (Legal Business Name): MARIO J SAMANIEGO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2569 E IDAHO AVE SUITE A
LAS CRUCES NM
88011-4578
US

IV. Provider business mailing address

2569 E IDAHO AVE SUITE A
LAS CRUCES NM
88011-4578
US

V. Phone/Fax

Practice location:
  • Phone: 505-523-1479
  • Fax: 505-523-2974
Mailing address:
  • Phone: 505-523-1479
  • Fax: 505-523-2974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1515
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: