MEDICARE: PUEBLO DE NINOS DENTAL, PC

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	1223P0221X	Pediatric Dentistry	DD3017	NM

General Provider Information

NPI Number	:	1720305105
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PUEBLO DE NINOS DENTAL, PC

Provider Business Mailing Address
First Line	:	3001 SANDIA CIR
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87507-2527
Country	:	US
Telephone Number	:	505-603-5594
Fax Number	:

Provider Business Practice Location Address
First Line	:	3252 CERRILLOS RD STE A
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87507-3001
Country	:	US
Telephone Number	:	505-603-5594
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DANIEL A BORRERO
Credential	:	DDS
Telephone Number	:	505-603-5594

Provider Enumeration Date	:	04/26/2010
Last Update Date	:	04/26/2010

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