Provider Demographics
NPI:1114216389
Name:LAS CRUCES DENTAL SOLUTIONS
Entity Type:Organization
Organization Name:LAS CRUCES DENTAL SOLUTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:575-541-0084
Mailing Address - Street 1:2001 E LOHMAN AVE STE 121
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-3195
Mailing Address - Country:US
Mailing Address - Phone:575-541-0084
Mailing Address - Fax:575-541-0087
Practice Address - Street 1:2001 E LOHMAN AVE STE 121
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3195
Practice Address - Country:US
Practice Address - Phone:575-541-0084
Practice Address - Fax:575-541-0087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-28
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODD3330122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty