Healthcare Provider Details

I. General information

NPI: 1346833878
Provider Name (Legal Business Name): SUMMIT FAMILY DENTAL OF BERNALILLO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2021
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7800 CARR WAY NE STE 105
RIO RANCHO NM
87144-0900
US

IV. Provider business mailing address

800 E 30TH ST BLDG 3
FARMINGTON NM
87401-9407
US

V. Phone/Fax

Practice location:
  • Phone: 505-327-9161
  • Fax:
Mailing address:
  • Phone: 505-327-9161
  • 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: LISA HODGES
Title or Position: OPERATIONS DIRECTOR
Credential:
Phone: 505-787-2965