Provider Demographics
NPI:1427394733
Name:NEW MEXICO PROFESSIONAL DENTAL
Entity Type:Organization
Organization Name:NEW MEXICO PROFESSIONAL DENTAL
Other - Org Name:NORTH SIDE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:806 CALLE MEJIA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1405
Mailing Address - Country:US
Mailing Address - Phone:217-540-5100
Mailing Address - Fax:
Practice Address - Street 1:806 CALLE MEJIA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1405
Practice Address - Country:US
Practice Address - Phone:217-540-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW MEXICO PROFESSIONAL DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-12-14
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty