MEDICARE: HIGHLANDS FAMILY DENTAL

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	DD3409	NM

General Provider Information

NPI Number	:	1942508643
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIGHLANDS FAMILY DENTAL

Provider Business Mailing Address
First Line	:	711 6TH ST
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4352
Country	:	US
Telephone Number	:	505-425-7574
Fax Number	:	505-425-7554

Provider Business Practice Location Address
First Line	:	711 6TH ST
Second Line	:
City	:	LAS VEGAS
State	:	NM
Zip	:	87701-4352
Country	:	US
Telephone Number	:	505-425-7574
Fax Number	:	505-425-7554

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. ELYSSA J HOOPES
Credential	:	DMD
Telephone Number	:	505-425-7574

Provider Enumeration Date	:	03/03/2011
Last Update Date	:	03/03/2011

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