Healthcare Provider Details

I. General information

NPI: 1972256865
Provider Name (Legal Business Name): ACCESS DENTAL OF TRIVIZ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2022
Last Update Date: 10/27/2022
Certification Date: 10/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1748 S TRIVIZ DR
LAS CRUCES NM
88001-5103
US

IV. Provider business mailing address

1748 S TRIVIZ DR
LAS CRUCES NM
88001-5103
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-1983
  • Fax: 575-522-3435
Mailing address:
  • Phone: 575-522-1983
  • Fax: 575-522-3435

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: RAUL CARRILLO
Title or Position: REGIONAL DIRECTOR
Credential:
Phone: 469-242-0743