=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174632350
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY DENTAL SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2116 HINKLE ST SE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87102-4930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-843-7493
-----------------------------------------------------
Fax | 505-843-7581
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2116 HINKLE ST SE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87102-4930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-843-7493
-----------------------------------------------------
Fax | 505-843-7581
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. DAVID A VARGAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 505-843-7493
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223D0001X
-----------------------------------------------------
Taxonomy Name | Public Health Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------