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General NPI Number Information
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NPI Number | 1528521374
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Entity Type | Organization
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Legal Business Name | FARMINGTON DENTAL CARE LLC
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Dates
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Enumeration Date | 04/09/2019
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Last Update Date | 04/29/2022
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Provider Practice Location Address
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Address Line | 4760 N BUTLER AVE STE C
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City | FARMINGTON
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State | NM
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Zip | 87401-0816
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Country | US
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Telephone | 505-326-2243
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Fax |
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Provider Business Mailing Address
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Address Line | 4760 N BUTLER AVE STE C
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City | FARMINGTON
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State | NM
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Zip | 87401-0816
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Country | US
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Telephone | 505-326-2243
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. RYAN H WILSON
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Credential |
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Telephone | 505-326-2243
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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