Healthcare Provider Details

I. General information

NPI: 1790953404
Provider Name (Legal Business Name): SANTA FE COMMUNITY COLLEGE DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2008
Last Update Date: 02/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 S RICHARDS AVE
SANTA FE NM
87508-4887
US

IV. Provider business mailing address

6401 S RICHARDS AVE
SANTA FE NM
87508-4887
US

V. Phone/Fax

Practice location:
  • Phone: 505-428-1710
  • Fax: 505-428-1511
Mailing address:
  • Phone: 505-428-1710
  • Fax: 505-428-1511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ALFRED OTERO
Title or Position: DENTIST
Credential: DDS
Phone: 505-428-1710