Provider Demographics
NPI:1497033310
Name:LAS CRUCES DENTAL ASSOCIATES PC
Entity Type:Organization
Organization Name:LAS CRUCES DENTAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMANIEGO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:575-437-7473
Mailing Address - Street 1:1022 9TH ST
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-6470
Mailing Address - Country:US
Mailing Address - Phone:575-437-7473
Mailing Address - Fax:575-437-0079
Practice Address - Street 1:1022 9TH ST
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-6470
Practice Address - Country:US
Practice Address - Phone:575-437-7473
Practice Address - Fax:575-437-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-26
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM6662830001Medicare NSC