Healthcare Provider Details

I. General information

NPI: 1508287541
Provider Name (Legal Business Name): SANTA FE ORAL SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2013
Last Update Date: 12/26/2019
Certification Date: 12/26/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 CALLE DELA VUEILA STE B103 B103
SANTA FE NM
87505-4749
US

IV. Provider business mailing address

2100 CALLE DELA VUEILA STE B103 B103
SANTA FE NM
87505-4749
US

V. Phone/Fax

Practice location:
  • Phone: 505-984-0694
  • Fax: 505-983-3270
Mailing address:
  • Phone: 505-984-0694
  • Fax: 505-983-3270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDD3886
License Number StateNM

VIII. Authorized Official

Name: MRS. REBECCA J MARTINEZ
Title or Position: PRACTICE MANAGER
Credential: DDS/MD
Phone: 505-984-0694