Healthcare Provider Details

I. General information

NPI: 1588186340
Provider Name (Legal Business Name): RED RIVER FAMILY DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 07/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 W MAIN STREET
RED RIVER NM
87558
US

IV. Provider business mailing address

2403 LACY LN
CARROLLTON TX
75006-6514
US

V. Phone/Fax

Practice location:
  • Phone: 575-754-2300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MARY PU
Title or Position: VP OF FINANCE
Credential:
Phone: 972-869-3789