Healthcare Provider Details

I. General information

NPI: 1720305105
Provider Name (Legal Business Name): PUEBLO DE NINOS DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2010
Last Update Date: 04/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3252 CERRILLOS RD STE A
SANTA FE NM
87507-3001
US

IV. Provider business mailing address

3001 SANDIA CIR
SANTA FE NM
87507-2527
US

V. Phone/Fax

Practice location:
  • Phone: 505-603-5594
  • Fax:
Mailing address:
  • Phone: 505-603-5594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDD3017
License Number StateNM

VIII. Authorized Official

Name: DANIEL A BORRERO
Title or Position: PRESIDENT
Credential: DDS
Phone: 505-603-5594