Healthcare Provider Details

I. General information

NPI: 1811527872
Provider Name (Legal Business Name): SSUN HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2020
Last Update Date: 01/18/2020
Certification Date: 01/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 SAINT MICHAELS DR STE 2
SANTA FE NM
87505-7604
US

IV. Provider business mailing address

10940 S PARKER RD
PARKER CO
80134-7440
US

V. Phone/Fax

Practice location:
  • Phone: 505-216-2364
  • Fax:
Mailing address:
  • Phone: 515-371-3782
  • Fax:

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: DR. FRED ANTHONY LACOURT
Title or Position: CHIEF DENTAL OFFICER
Credential: DDS
Phone: 414-303-7484