Provider Demographics
NPI:1033400601
Name:SAN MIGUEL DENTAL
Entity Type:Organization
Organization Name:SAN MIGUEL DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILFRED
Authorized Official - Middle Name:B
Authorized Official - Last Name:PACHECO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-425-6434
Mailing Address - Street 1:2503 RIDGE RUNNER RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4972
Mailing Address - Country:US
Mailing Address - Phone:505-425-6434
Mailing Address - Fax:505-425-6464
Practice Address - Street 1:2503 RIDGE RUNNER RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4972
Practice Address - Country:US
Practice Address - Phone:505-425-6434
Practice Address - Fax:505-425-6464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD16061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty