Provider Demographics
NPI:1417377177
Name:FAMILIA DENTAL LOS LUNAS LLC
Entity Type:Organization
Organization Name:FAMILIA DENTAL LOS LUNAS LLC
Other - Org Name:FAMILIA DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING & PAYER RELATIONS MAN
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:CPCS
Authorized Official - Phone:847-453-7396
Mailing Address - Street 1:2050 EAST ALGONQUIN ROAD
Mailing Address - Street 2:SUITE 610
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4166
Mailing Address - Country:US
Mailing Address - Phone:847-453-7396
Mailing Address - Fax:847-453-7396
Practice Address - Street 1:1620 MAIN ST NW
Practice Address - Street 2:STE D
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-4891
Practice Address - Country:US
Practice Address - Phone:505-565-0651
Practice Address - Fax:505-565-2031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-21
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No122300000XDental ProvidersDentistGroup - Single Specialty