Provider Demographics
NPI:1417366808
Name:SUMMIT FAMILY DENTAL OF CORTEZ, PLLC
Entity Type:Organization
Organization Name:SUMMIT FAMILY DENTAL OF CORTEZ, PLLC
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 1:111 S SLIGO
Mailing Address - Street 2:BUILDING A
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321
Mailing Address - Country:US
Mailing Address - Phone:505-326-6800
Mailing Address - Fax:505-326-6820
Practice Address - Street 1:111 S SLIGO
Practice Address - Street 2:BUILDING A
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321
Practice Address - Country:US
Practice Address - Phone:505-326-6800
Practice Address - Fax:505-326-6820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-11
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty