Provider Demographics
NPI:1437514858
Name:CHAMISA HILLS FAMILY DENTAL
Entity Type:Organization
Organization Name:CHAMISA HILLS FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:CANDELARIA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-891-3190
Mailing Address - Street 1:1105 GOLF COURSE RD SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124
Mailing Address - Country:US
Mailing Address - Phone:505-891-3190
Mailing Address - Fax:505-994-2053
Practice Address - Street 1:1105 GOLF COURSE RD SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124
Practice Address - Country:US
Practice Address - Phone:505-891-3190
Practice Address - Fax:505-994-2053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2298261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental