Healthcare Provider Details

I. General information

NPI: 1376618967
Provider Name (Legal Business Name): CHILDRENS DENTAL CLINIC OF RUIDOSO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 09/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 MECHEM SIERRA MALL #5
RUIDOSO NM
88345-6911
US

IV. Provider business mailing address

721 MECHEM SIERRA MALL #5
RUIDOSO NM
88345-6911
US

V. Phone/Fax

Practice location:
  • Phone: 505-257-0246
  • Fax: 505-257-0249
Mailing address:
  • Phone: 505-257-0246
  • Fax: 505-257-0249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDD1984
License Number StateNM

VIII. Authorized Official

Name: DR. MACK ALLEN MCGUINNESS
Title or Position: PRESIDENT
Credential: DDS
Phone: 505-257-0246