Healthcare Provider Details

I. General information

NPI: 1518195676
Provider Name (Legal Business Name): HOWARD HASSELL PACK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2009
Last Update Date: 09/19/2022
Certification Date: 09/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 LONGVIEW DR. STE. A
WHITE ROCK NM
87547
US

IV. Provider business mailing address

106 LONGVIEW DR. STE. A
WHITE ROCK NM
87547
US

V. Phone/Fax

Practice location:
  • Phone: 970-799-2181
  • Fax: 505-672-0840
Mailing address:
  • Phone: 970-799-2181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD5673
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10266
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: