Healthcare Provider Details

I. General information

NPI: 1396341541
Provider Name (Legal Business Name): SILVER CITY DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2020
Last Update Date: 12/11/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 E 32ND ST
SILVER CITY NM
88061-7252
US

IV. Provider business mailing address

1340 E 32ND ST
SILVER CITY NM
88061-7252
US

V. Phone/Fax

Practice location:
  • Phone: 575-538-5664
  • Fax: 575-388-4087
Mailing address:
  • Phone: 575-538-5664
  • Fax: 575-388-4087

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: DR. JUSTIN PORTER
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 575-538-5664