Healthcare Provider Details

I. General information

NPI: 1184157315
Provider Name (Legal Business Name): NORTHERN NM CENTER FOR COSMETIC DENTISTRY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2017
Last Update Date: 05/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1337 GUSDORF RD SUITE A
TAOS NM
87571-6294
US

IV. Provider business mailing address

1337 GUSDORF RD SUITE A
TAOS NM
87571-6294
US

V. Phone/Fax

Practice location:
  • Phone: 575-751-9661
  • Fax: 575-751-9689
Mailing address:
  • Phone: 575-751-9661
  • Fax: 575-751-9689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDD3454
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDD1576
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDD4507
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD1953
License Number StateNM

VIII. Authorized Official

Name: DR. KELLIE A HARRIS
Title or Position: PRESIDENT
Credential: DDS
Phone: 575-751-9661