Provider Demographics
NPI: | 1033708235 |
---|---|
Name: | PROFESSIONAL DENTAL CARE OF NORTHERN NEW MEXICO III |
Entity Type: | Organization |
Organization Name: | PROFESSIONAL DENTAL CARE OF NORTHERN NEW MEXICO III |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CLINICAL MANAGER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | CARY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | LACOUTURE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 303-521-5701 |
Mailing Address - Street 1: | 10233 S PARKER RD STE 107 |
Mailing Address - Street 2: | |
Mailing Address - City: | PARKER |
Mailing Address - State: | CO |
Mailing Address - Zip Code: | 80134-9314 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 303-521-5701 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2500 7TH ST STE H |
Practice Address - Street 2: | |
Practice Address - City: | LAS VEGAS |
Practice Address - State: | NM |
Practice Address - Zip Code: | 87701-4947 |
Practice Address - Country: | US |
Practice Address - Phone: | 505-718-9156 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | Yes |
Parent Organization LBN: | SSUN HEALTH, LLC |
Parent Organization TIN: | <UNAVAIL> |
Enumeration Date: | 2021-01-12 |
Last Update Date: | 2021-01-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |