Healthcare Provider Details

I. General information

NPI: 1962889030
Provider Name (Legal Business Name): DENTAL DEL SOL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2015
Last Update Date: 04/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1533 S SAINT FRANCIS DR STE F
SANTA FE NM
87505-4032
US

IV. Provider business mailing address

1533 S SAINT FRANCIS DR STE F
SANTA FE NM
87505-4032
US

V. Phone/Fax

Practice location:
  • Phone: 505-954-1073
  • Fax:
Mailing address:
  • Phone: 505-954-1073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDD2992
License Number StateNM

VIII. Authorized Official

Name: DR. JACQUELYN GOMEZ-BARTEK
Title or Position: OWNER DENTIST
Credential: D.D.S.
Phone: 505-310-3603