Provider Demographics
NPI:1366690216
Name:AFFORDABLE DENTAL LLC
Entity Type:Organization
Organization Name:AFFORDABLE DENTAL LLC
Other - Org Name:LAS CRUCES FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EILEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:AMBRIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-541-0072
Mailing Address - Street 1:1423 S DON ROSER DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4515
Mailing Address - Country:US
Mailing Address - Phone:575-541-0072
Mailing Address - Fax:575-541-1908
Practice Address - Street 1:1423 DON ROSER DR.
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4515
Practice Address - Country:US
Practice Address - Phone:575-541-0072
Practice Address - Fax:575-541-1908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-04
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD26011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM21223025Medicaid