Healthcare Provider Details

I. General information

NPI: 1104378314
Provider Name (Legal Business Name): DESERT MOUNTAIN SKIN CANCER SURGERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 GALISTEO STREET SUITE N-9B
SANTA FE NM
87505
US

IV. Provider business mailing address

PO BOX 604
PLACITAS NM
87043-0604
US

V. Phone/Fax

Practice location:
  • Phone: 505-980-8738
  • Fax: 505-404-8423
Mailing address:
  • Phone: 505-980-8738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberMD2011-0829
License Number StateNM

VIII. Authorized Official

Name: DIANE MARIE REISINGER
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 505-980-8738