Provider Demographics
NPI:1376710483
Name:DENTISTRY ON ST. MICHAELS LLC
Entity Type:Organization
Organization Name:DENTISTRY ON ST. MICHAELS LLC
Other - Org Name:SANTA FE PLACE DENTAL PRACTICE LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SENIOR PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-982-4867
Mailing Address - Street 1:435 SAINT MICHAELS DR STE B201
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7681
Mailing Address - Country:US
Mailing Address - Phone:505-982-4867
Mailing Address - Fax:505-424-8535
Practice Address - Street 1:435 SAINT MICHAELS DR STE B201
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7681
Practice Address - Country:US
Practice Address - Phone:505-982-4867
Practice Address - Fax:505-424-8535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM183394OtherUNITED CONCORDIA