Healthcare Provider Details

I. General information

NPI: 1558746099
Provider Name (Legal Business Name): LAS CRUCES SMILES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2015
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 COMMERCE DR STE B
LAS CRUCES NM
88011-8209
US

IV. Provider business mailing address

1160 COMMERCE DR STE B
LAS CRUCES NM
88011-8209
US

V. Phone/Fax

Practice location:
  • Phone: 575-640-3367
  • Fax:
Mailing address:
  • Phone: 575-640-3367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD4079
License Number StateNM

VIII. Authorized Official

Name: DR. KEITH CRAIG COOMBS
Title or Position: ORTHODONTIST/OWNER
Credential: DDS, MS
Phone: 575-640-3367