=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508287541
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANTA FE ORAL SURGERY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2013
-----------------------------------------------------
Last Update Date | 12/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 CALLE DELA VUEILA STE B103 B103
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-4749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-984-0694
-----------------------------------------------------
Fax | 505-983-3270
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2100 CALLE DELA VUEILA STE B103 B103
-----------------------------------------------------
City | SANTA FE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87505-4749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-984-0694
-----------------------------------------------------
Fax | 505-983-3270
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | MRS. REBECCA J MARTINEZ
-----------------------------------------------------
Credential | DDS/MD
-----------------------------------------------------
Telephone | 505-984-0694
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DD3886
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------