Healthcare Provider Details

I. General information

NPI: 1457278640
Provider Name (Legal Business Name): ON THE CUSP DENTAL STUDIO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MANZANARES AVE E
SOCORRO NM
87801-4215
US

IV. Provider business mailing address

200 MANZANARES AVE E
SOCORRO NM
87801-4215
US

V. Phone/Fax

Practice location:
  • Phone: 575-835-3662
  • Fax: 575-838-1631
Mailing address:
  • Phone: 575-835-3662
  • Fax: 575-838-1631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN B WAITES
Title or Position: OWNER
Credential: DDS
Phone: 509-750-8899