MEDICARE: DENTISTRY ON ST. MICHAELS LLC

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	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	183394	OTHER	NM	UNITED CONCORDIA

General Provider Information

NPI Number	:	1376710483
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTISTRY ON ST. MICHAELS LLC

Provider Business Mailing Address
First Line	:	435 SAINT MICHAELS DR STE B201
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-7681
Country	:	US
Telephone Number	:	505-982-4867
Fax Number	:	505-424-8535

Provider Business Practice Location Address
First Line	:	435 SAINT MICHAELS DR STE B201
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87505-7681
Country	:	US
Telephone Number	:	505-982-4867
Fax Number	:	505-424-8535

Authorized Official
Title or Position	:	SENIOR PRACTICE MANAGER
Name	:	CHRISTINE GARRIS
Credential	:
Telephone Number	:	505-982-4867

Provider Enumeration Date	:	05/08/2008
Last Update Date	:	04/30/2019

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