Provider Demographics
NPI:1225058761
Name:ENCINO DENTAL CARE, INC.
Entity Type:Organization
Organization Name:ENCINO DENTAL CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:D
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:RDH, DOM
Authorized Official - Phone:505-843-9636
Mailing Address - Street 1:717 ENCINO PLACE NE SUITE 7
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102
Mailing Address - Country:US
Mailing Address - Phone:505-843-9636
Mailing Address - Fax:505-843-6277
Practice Address - Street 1:717 ENCINO PLACE NE SUITE 7
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102
Practice Address - Country:US
Practice Address - Phone:505-843-9636
Practice Address - Fax:505-843-6277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM38759501Medicaid