Healthcare Provider Details

I. General information

NPI: 1386955888
Provider Name (Legal Business Name): BRYCE HEINER, DMD, MD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2010
Last Update Date: 04/29/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 TELSHOR CT
LAS CRUCES NM
88011-8245
US

IV. Provider business mailing address

2103 TELSHOR CT
LAS CRUCES NM
88011-8245
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-8800
  • Fax:
Mailing address:
  • Phone: 575-522-8800
  • Fax: 575-522-8800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberDD3068
License Number StateNM

VIII. Authorized Official

Name: DR. BRYCE HEINER
Title or Position: CEO
Credential: DMD, MD
Phone: 575-522-8800