Provider Demographics
NPI:1295215713
Name:SANTA TERESA COSMETIC AND FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:SANTA TERESA COSMETIC AND FAMILY DENTISTRY LLC
Other - Org Name:SANTA TERESA SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:NOHA
Authorized Official - Middle Name:
Authorized Official - Last Name:OUSHY EISSA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:575-332-4047
Mailing Address - Street 1:103 LIVINGSTON LOOP UNIT B
Mailing Address - Street 2:
Mailing Address - City:SANTA TERESA
Mailing Address - State:NM
Mailing Address - Zip Code:88008-9762
Mailing Address - Country:US
Mailing Address - Phone:575-332-4047
Mailing Address - Fax:575-332-4201
Practice Address - Street 1:103 LIVINGSTON LOOP UNIT B
Practice Address - Street 2:
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-9762
Practice Address - Country:US
Practice Address - Phone:575-332-4047
Practice Address - Fax:575-332-4201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty