Provider Demographics
NPI:1336505916
Name:CLOVIS FAMILY DENTISTRY, LLC
Entity Type:Organization
Organization Name:CLOVIS FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRIDGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-356-8514
Mailing Address - Street 1:2000 W 21ST ST STE L1
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-1400
Mailing Address - Country:US
Mailing Address - Phone:575-762-8000
Mailing Address - Fax:
Practice Address - Street 1:2000 W 21ST ST STE L1
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-1400
Practice Address - Country:US
Practice Address - Phone:575-762-8000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental