Healthcare Provider Details

I. General information

NPI: 1619006376
Provider Name (Legal Business Name): CAMERON DOC HOLLYWOOD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 SPRUCE AVE
LAS CRUCES NM
88001-2353
US

IV. Provider business mailing address

808 SPRUCE AVE
LAS CRUCES NM
88001-2353
US

V. Phone/Fax

Practice location:
  • Phone: 505-526-3066
  • Fax:
Mailing address:
  • Phone: 505-526-3066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1491
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: