Provider Demographics
NPI:1346833878
Name:SUMMIT FAMILY DENTAL OF BERNALILLO, LLC
Entity Type:Organization
Organization Name:SUMMIT FAMILY DENTAL OF BERNALILLO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:HODGES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-787-2965
Mailing Address - Street 1:800 E 30TH ST BLDG 3
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-9407
Mailing Address - Country:US
Mailing Address - Phone:505-327-9161
Mailing Address - Fax:
Practice Address - Street 1:7800 CARR WAY NE STE 105
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-0900
Practice Address - Country:US
Practice Address - Phone:505-327-9161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-16
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental