Provider Demographics
NPI:1083968077
Name:CLOVIS HOSPITAL DENTISTRY PC
Entity Type:Organization
Organization Name:CLOVIS HOSPITAL DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FALON
Authorized Official - Middle Name:
Authorized Official - Last Name:WAISATH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:575-763-9382
Mailing Address - Street 1:1552 BOSC CT
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-2334
Mailing Address - Country:US
Mailing Address - Phone:575-763-9382
Mailing Address - Fax:
Practice Address - Street 1:2100 N MARTIN LUTHER KING JR. BLVD
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:575-763-9382
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD35531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty