Healthcare Provider Details

I. General information

NPI: 1194358762
Provider Name (Legal Business Name): RATON FAMILY DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2020
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S 2ND ST STE C
RATON NM
87740-2326
US

IV. Provider business mailing address

132 N COMMERCIAL ST UNIT 2
TRINIDAD CO
81082-2655
US

V. Phone/Fax

Practice location:
  • Phone: 801-717-8637
  • Fax:
Mailing address:
  • Phone: 801-717-8637
  • Fax:

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. STEPHEN PAUL DIXON
Title or Position: OWNER
Credential: DMD
Phone: 801-717-8637