Healthcare Provider Details

I. General information

NPI: 1417377177
Provider Name (Legal Business Name): FAMILIA DENTAL LOS LUNAS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 MAIN ST NW STE D
LOS LUNAS NM
87031-4891
US

IV. Provider business mailing address

2050 EAST ALGONQUIN ROAD SUITE 610
SCHAUMBURG IL
60173-4166
US

V. Phone/Fax

Practice location:
  • Phone: 505-565-0651
  • Fax: 505-565-2031
Mailing address:
  • Phone: 847-453-7396
  • Fax: 847-453-7396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. BRANDON ALEXANDER TAYLOR
Title or Position: CREDENTIALING & PAYER RELATIONS MAN
Credential: CPCS
Phone: 847-453-7396