=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164725503
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNDANCE DENTAL CARE OF RIO RANCHO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2010
-----------------------------------------------------
Last Update Date | 06/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 770 BROADMOOR BLVD NE
-----------------------------------------------------
City | RIO RANCHO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-891-0554
-----------------------------------------------------
Fax | 505-891-0552
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 770 BROADMOOR BLVD. NE
-----------------------------------------------------
City | RIO RANCHO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-891-0554
-----------------------------------------------------
Fax | 505-891-0552
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MICHELLE BROWN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 505-326-6800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DD2872
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DD3016
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DD2287
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------