MEDICARE: DR. HOWARD HASSELL PACK DMD

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	390200000X	Student in an Organized Health Care Education/Training Program
2	1223G0001X	General Practice Dentistry	DD5673	NM
3	1223G0001X	General Practice Dentistry	10266	CO

General Provider Information

NPI Number	:	1518195676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HOWARD HASSELL PACK DMD

Provider Business Mailing Address
First Line	:	106 LONGVIEW DR. STE. A
Second Line	:
City	:	WHITE ROCK
State	:	NM
Zip	:	87547
Country	:	US
Telephone Number	:	970-799-2181
Fax Number	:

Provider Business Practice Location Address
First Line	:	106 LONGVIEW DR. STE. A
Second Line	:
City	:	WHITE ROCK
State	:	NM
Zip	:	87547
Country	:	US
Telephone Number	:	970-799-2181
Fax Number	:	505-672-0840

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

Provider Enumeration Date	:	06/29/2009
Last Update Date	:	09/19/2022

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