Healthcare Provider Details

I. General information

NPI: 1427394733
Provider Name (Legal Business Name): NEW MEXICO PROFESSIONAL DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2012
Last Update Date: 12/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 CALLE MEJIA
SANTA FE NM
87501-1405
US

IV. Provider business mailing address

806 CALLE MEJIA
SANTA FE NM
87501-1405
US

V. Phone/Fax

Practice location:
  • Phone: 217-540-5100
  • Fax:
Mailing address:
  • Phone: 217-540-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MARIE KUHL
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 217-540-5100