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General NPI Number Information
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NPI Number | 1396174116
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Entity Type | Organization
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Legal Business Name | UNIVERSITY FAMILY DENTAL PC
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Dates
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Enumeration Date | 11/02/2013
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Last Update Date | 11/02/2013
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Provider Practice Location Address
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Address Line | 705 E UNIVERSITY AVE STE B
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City | LAS CRUCES
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State | NM
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Zip | 88001-5637
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Country | US
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Telephone | 575-521-0127
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Fax | 575-647-9533
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Provider Business Mailing Address
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Address Line | 705 E UNIVERSITY AVE STE B
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City | LAS CRUCES
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State | NM
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Zip | 88001-5637
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Country | US
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Telephone | 575-521-0127
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Fax | 575-647-9533
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Authorized Official
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Title or Position | DENTIST
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Name | KIMBERLY H MARTIN
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Credential | DMD
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Telephone | 575-521-0127
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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 | 2498
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2317
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License Number State | NM
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