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General NPI Number Information
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NPI Number | 1285091181
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Entity Type | Organization
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Legal Business Name | SOUTHERN NEW MEXICO ORTHODONTICS LLC
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Dates
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Enumeration Date | 01/22/2016
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Last Update Date | 01/22/2016
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Provider Practice Location Address
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Address Line | 1310 E PINE ST STE B
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City | DEMING
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State | NM
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Zip | 88030-7003
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Country | US
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Telephone | 575-544-9999
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Fax | 575-546-1070
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Provider Business Mailing Address
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Address Line | 1310 E PINE ST STE B
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City | DEMING
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State | NM
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Zip | 88030-7003
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Country | US
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Telephone | 575-544-9999
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Fax | 575-546-1070
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | EBONIE MARIE BOGDAN
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Credential |
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Telephone | 505-892-9010
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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 | DD4435
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License Number State | NM
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