Provider Demographics
NPI:1558471037
Name:LINES, DEREK CHRISTIAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:CHRISTIAN
Last Name:LINES
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5343 WYOMING BLVD NE STE A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3199
Mailing Address - Country:US
Mailing Address - Phone:505-822-8777
Mailing Address - Fax:505-822-1928
Practice Address - Street 1:5343 WYOMING BLVD NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3199
Practice Address - Country:US
Practice Address - Phone:505-822-8777
Practice Address - Fax:505-822-1928
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD23661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice