Healthcare Provider Details

I. General information

NPI: 1932643038
Provider Name (Legal Business Name): SOCORRO DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2016
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204B NEEL AVE
SOCORRO NM
87801-4649
US

IV. Provider business mailing address

204B NEEL AVE
SOCORRO NM
87801-4649
US

V. Phone/Fax

Practice location:
  • Phone: 267-318-6667
  • Fax:
Mailing address:
  • Phone: 575-993-5032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD4651
License Number StateNM

VIII. Authorized Official

Name: DR. GEORGE HANNA
Title or Position: OWNER
Credential:
Phone: 575-993-5032