Provider Demographics
NPI:1124184213
Name:PACHECO, WIL B (DDS)
Entity Type:Individual
Prefix:DR
First Name:WIL
Middle Name:B
Last Name:PACHECO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:WILFRED
Other - Middle Name:B
Other - Last Name:PACHECO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 349
Mailing Address - Street 2:
Mailing Address - City:FORT SUMNER
Mailing Address - State:NM
Mailing Address - Zip Code:88119-0349
Mailing Address - Country:US
Mailing Address - Phone:575-355-2414
Mailing Address - Fax:
Practice Address - Street 1:546 N 10TH STREET
Practice Address - Street 2:
Practice Address - City:FORT SUMNER
Practice Address - State:NM
Practice Address - Zip Code:88119
Practice Address - Country:US
Practice Address - Phone:575-355-2414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-31
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM16061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM87312Medicaid