Healthcare Provider Details

I. General information

NPI: 1376710483
Provider Name (Legal Business Name): DENTISTRY ON ST. MICHAELS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 SAINT MICHAELS DR STE B201
SANTA FE NM
87505-7681
US

IV. Provider business mailing address

435 SAINT MICHAELS DR STE B201
SANTA FE NM
87505-7681
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-4867
  • Fax: 505-424-8535
Mailing address:
  • Phone: 505-982-4867
  • Fax: 505-424-8535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CHRISTINE GARRIS
Title or Position: SENIOR PRACTICE MANAGER
Credential:
Phone: 505-982-4867