Provider Demographics
NPI:1306415955
Name:PROFESSIONAL DENTAL CARE OF SOUTHERN NM I PLLC
Entity Type:Organization
Organization Name:PROFESSIONAL DENTAL CARE OF SOUTHERN NM I PLLC
Other - Org Name:PETER THOMPSON, DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARY
Authorized Official - Middle Name:
Authorized Official - Last Name:LACOUTURE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-521-5701
Mailing Address - Street 1:123 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-6201
Mailing Address - Country:US
Mailing Address - Phone:575-448-8863
Mailing Address - Fax:
Practice Address - Street 1:123 W 2ND ST
Practice Address - Street 2:
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6201
Practice Address - Country:US
Practice Address - Phone:575-448-8863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROFESSIONAL DENTAL CARE PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-18
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty