Provider Demographics
NPI:1093261455
Name:EASTERN NEW MEXICO ENDODONTICS, PC
Entity Type:Organization
Organization Name:EASTERN NEW MEXICO ENDODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:RICKY
Authorized Official - Last Name:SOUTHARD
Authorized Official - Suffix:
Authorized Official - Credentials:FACHE, FHFMA
Authorized Official - Phone:806-797-4455
Mailing Address - Street 1:2000 W 21ST ST
Mailing Address - Street 2:SUITE L1
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-4087
Mailing Address - Country:US
Mailing Address - Phone:575-762-8000
Mailing Address - Fax:575-763-0418
Practice Address - Street 1:2000 W 21ST ST
Practice Address - Street 2:SUITE L1
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4087
Practice Address - Country:US
Practice Address - Phone:575-762-8000
Practice Address - Fax:575-763-0418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-26
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental