Healthcare Provider Details

I. General information

NPI: 1386634087
Provider Name (Legal Business Name): ROGER J AMES D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 06/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 MORA CLINIC RD
MORA NM
87732
US

IV. Provider business mailing address

PO BOX 209
MORA NM
87732-0209
US

V. Phone/Fax

Practice location:
  • Phone: 575-387-2481
  • Fax: 575-387-9149
Mailing address:
  • Phone: 575-387-2481
  • Fax: 575-387-9149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD2247
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: