Healthcare Provider Details

I. General information

NPI: 1295849792
Provider Name (Legal Business Name): BEN M SMITH DMD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 N UNION AVE STE E
ROSWELL NM
88201-3068
US

IV. Provider business mailing address

PO BOX 8244
ROSWELL NM
88202-8244
US

V. Phone/Fax

Practice location:
  • Phone: 575-910-6748
  • Fax: 575-208-0780
Mailing address:
  • Phone: 575-624-2095
  • Fax: 575-627-5721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberNM1575
License Number StateNM

VIII. Authorized Official

Name: BEN M. SMITH
Title or Position: OWNER/PRESIDENT
Credential: DMD
Phone: 575-624-2095