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General NPI Number Information
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NPI Number | 1114216389
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Entity Type | Organization
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Legal Business Name | LAS CRUCES DENTAL SOLUTIONS
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Dates
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Enumeration Date | 03/28/2011
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Last Update Date | 03/28/2011
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Provider Practice Location Address
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Address Line | 2001 E LOHMAN AVE STE 121
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City | LAS CRUCES
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State | NM
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Zip | 88001-3195
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Country | US
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Telephone | 575-541-0084
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Fax | 575-541-0087
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Provider Business Mailing Address
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Address Line | 2001 E LOHMAN AVE STE 121
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City | LAS CRUCES
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State | NM
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Zip | 88001-3195
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Country | US
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Telephone | 575-541-0084
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Fax | 575-541-0087
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Authorized Official
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Title or Position | OWNER
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Name | MATTHEW PETERSON
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Credential | DDS
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Telephone | 575-541-0084
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DD3330
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License Number State | CO
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