MEDICARE: DR. DAVID A SUDIMACK DDS

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	2258	NM

General Provider Information

NPI Number	:	1497883490
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID A SUDIMACK DDS

Provider Business Mailing Address
First Line	:	2205 S SOLANO DR
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88001-5503
Country	:	US
Telephone Number	:	505-522-7320
Fax Number	:	505-522-6395

Provider Business Practice Location Address
First Line	:	2205 S SOLANO DR
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88001-5503
Country	:	US
Telephone Number	:	505-522-7320
Fax Number	:	505-522-6395

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	07/08/2007

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