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General NPI Number Information
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NPI Number | 1093261455
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Entity Type | Organization
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Legal Business Name | EASTERN NEW MEXICO ENDODONTICS, PC
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Dates
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Enumeration Date | 08/26/2016
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Last Update Date | 08/26/2016
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Provider Practice Location Address
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Address Line | 2000 W 21ST ST SUITE L1
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City | CLOVIS
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State | NM
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Zip | 88101-4087
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Country | US
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Telephone | 575-762-8000
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Fax | 575-763-0418
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Provider Business Mailing Address
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Address Line | 2000 W 21ST ST SUITE L1
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City | CLOVIS
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State | NM
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Zip | 88101-4087
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Country | US
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Telephone | 575-762-8000
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Fax | 575-763-0418
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. CHAD RICKY SOUTHARD
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Credential | FACHE, FHFMA
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Telephone | 806-797-4455
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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