Provider Demographics
NPI:1346952942
Name:LAS CRUCES DENTAL SOLUTIONS LLC
Entity Type:Organization
Organization Name:LAS CRUCES DENTAL SOLUTIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATHEW
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:575-527-4746
Mailing Address - Street 1:2001 E LOHMAN AVE STE 121
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-3195
Mailing Address - Country:US
Mailing Address - Phone:575-527-4746
Mailing Address - Fax:575-904-7152
Practice Address - Street 1:2001 E LOHMAN AVE STE 121
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3195
Practice Address - Country:US
Practice Address - Phone:575-527-4746
Practice Address - Fax:575-904-7152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty