Healthcare Provider Details

I. General information

NPI: 1164725503
Provider Name (Legal Business Name): SUNDANCE DENTAL CARE OF RIO RANCHO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2010
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 BROADMOOR BLVD NE
RIO RANCHO NM
87124
US

IV. Provider business mailing address

770 BROADMOOR BLVD. NE
RIO RANCHO NM
87124
US

V. Phone/Fax

Practice location:
  • Phone: 505-891-0554
  • Fax: 505-891-0552
Mailing address:
  • Phone: 505-891-0554
  • Fax: 505-891-0552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2872
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD3016
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2287
License Number StateNM

VIII. Authorized Official

Name: MICHELLE BROWN
Title or Position: MANAGER
Credential:
Phone: 505-326-6800