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General NPI Number Information
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NPI Number | 1184157315
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Entity Type | Organization
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Legal Business Name | NORTHERN NM CENTER FOR COSMETIC DENTISTRY INC
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Dates
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Enumeration Date | 04/05/2017
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Last Update Date | 05/04/2017
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Provider Practice Location Address
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Address Line | 1337 GUSDORF RD SUITE A
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City | TAOS
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State | NM
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Zip | 87571-6294
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Country | US
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Telephone | 575-751-9661
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Fax | 575-751-9689
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Provider Business Mailing Address
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Address Line | 1337 GUSDORF RD SUITE A
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City | TAOS
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State | NM
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Zip | 87571-6294
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Country | US
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Telephone | 575-751-9661
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Fax | 575-751-9689
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KELLIE A HARRIS
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Credential | DDS
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Telephone | 575-751-9661
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | DD3454
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | DD1576
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License Number State | NM
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Taxonomy #3
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | DD4507
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License Number State | NM
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Taxonomy #4
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DD1953
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License Number State | NM
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