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General NPI Number Information
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NPI Number | 1740498179
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Entity Type | Organization
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Legal Business Name | PORTALES DENTAL ARTS CENTER INC
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Dates
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Enumeration Date | 05/18/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1521 W 18TH ST
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City | PORTALES
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State | NM
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Zip | 88130-7018
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Country | US
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Telephone | 505-356-8514
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Fax |
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Provider Business Mailing Address
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Address Line | 1521 W 18TH ST
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City | PORTALES
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State | NM
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Zip | 88130-7018
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Country | US
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Telephone | 505-356-8514
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | BUCK R WILSON
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Credential | D.D.S.
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Telephone | 505-356-8514
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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 | DD916
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License Number State | NM
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