MEDICARE: PROFESSIONAL DENTAL CARE OF NORTHERN NEW MEXICO III

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1033708235
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL DENTAL CARE OF NORTHERN NEW MEXICO III

Provider Business Mailing Address
First Line	:	10233 S PARKER RD STE 107
Second Line	:
City	:	PARKER
State	:	CO
Zip	:	80134-9314
Country	:	US
Telephone Number	:	303-521-5701
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 7TH ST STE H
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4947
Country	:	US
Telephone Number	:	505-718-9156
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL MANAGER
Name	:	CARY LACOUTURE
Credential	:	DDS
Telephone Number	:	303-521-5701

Provider Enumeration Date	:	01/12/2021
Last Update Date	:	01/12/2021

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