Healthcare Provider Details

I. General information

NPI: 1114753837
Provider Name (Legal Business Name): FULL SMILE EASTERN FAMILY DENTISTRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 W 18TH ST
PORTALES NM
88130-7018
US

IV. Provider business mailing address

2201 CIVIC CIR STE 600
AMARILLO TX
79109-1817
US

V. Phone/Fax

Practice location:
  • Phone: 806-353-1055
  • Fax:
Mailing address:
  • Phone: 806-353-1055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: LAUREN AMES HODGES
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 806-353-1055