Provider Demographics
NPI:1275230518
Name:AGAVE DENTAL BRIGHT STAR PLLC
Entity Type:Organization
Organization Name:AGAVE DENTAL BRIGHT STAR PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:385-335-0928
Mailing Address - Street 1:2010 E LOHMAN AVE STE A
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-3109
Mailing Address - Country:US
Mailing Address - Phone:575-526-4334
Mailing Address - Fax:575-526-7863
Practice Address - Street 1:2010 E LOHMAN AVE STE A
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3109
Practice Address - Country:US
Practice Address - Phone:575-526-4334
Practice Address - Fax:575-526-7863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty