Healthcare Provider Details

I. General information

NPI: 1710052543
Provider Name (Legal Business Name): MAIN STREET DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 MAIN ST SW
LOS LUNAS NM
87031-8308
US

IV. Provider business mailing address

705 MAIN ST SW
LOS LUNAS NM
87031-8308
US

V. Phone/Fax

Practice location:
  • Phone: 505-865-3395
  • Fax: 505-865-1414
Mailing address:
  • Phone: 505-865-3395
  • Fax: 505-865-1414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. RONALD PHILIP UILKIE
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 505-865-3395