=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588186340
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RED RIVER FAMILY DENTISTRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2017
-----------------------------------------------------
Last Update Date | 07/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 612 W MAIN STREET
-----------------------------------------------------
City | RED RIVER
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87558
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-754-2300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2403 LACY LN
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75006-6514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF FINANCE
-----------------------------------------------------
Name | MARY PU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-869-3789
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------