Healthcare Provider Details

I. General information

NPI: 1245351675
Provider Name (Legal Business Name): PERFECT TEETH - RIO RANCHO P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 ARROWHEAD RIDGE DR SE
RIO RANCHO NM
87124-5932
US

IV. Provider business mailing address

4500 ARROWHEAD RIDGE DR SE
RIO RANCHO NM
87124-5932
US

V. Phone/Fax

Practice location:
  • Phone: 505-994-1110
  • Fax: 505-994-1112
Mailing address:
  • Phone: 505-994-1110
  • Fax: 505-994-1112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1398
License Number StateNM

VIII. Authorized Official

Name: LAURIE SUMMERS
Title or Position: CREDENTIALING
Credential:
Phone: 303-285-6098