Healthcare Provider Details

I. General information

NPI: 1053629089
Provider Name (Legal Business Name): OMS OF SE NM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2010
Last Update Date: 09/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 N. UNION STE. E OMS OF SE NM, LLC
ROSWELL NM
88201-3068
US

IV. Provider business mailing address

207 N. UNION STE. E OMS OF SE NM, LLC
ROSWELL NM
88201-3068
US

V. Phone/Fax

Practice location:
  • Phone: 575-623-5711
  • Fax: 575-623-8628
Mailing address:
  • Phone: 575-623-5711
  • Fax: 575-623-8628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MRS. SHERRY C ECKEL
Title or Position: OWNER
Credential:
Phone: 575-623-5711