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General NPI Number Information
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NPI Number | 1679017453
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Entity Type | Organization
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Legal Business Name | EMBUDO DENTAL CENTER LLC
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Dates
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Enumeration Date | 12/13/2016
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Last Update Date | 12/13/2016
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Provider Practice Location Address
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Address Line | 1102 STATE HIGHWAY 68
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City | EMBUDO
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State | NM
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Zip | 87531-0037
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Country | US
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Telephone | 505-579-4680
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Fax | 505-579-4074
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Provider Business Mailing Address
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Address Line | PO BOX 37 1102 STATE HIGHWAY 68
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City | EMBUDO
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State | NM
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Zip | 87531-0037
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Country | US
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Telephone | 505-579-4680
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Fax | 505-579-4074
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | KELLIE A HARRIS
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Credential | DDS
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Telephone | 505-579-4680
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DD1074
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DD1953
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License Number State | NM
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