Provider Demographics
NPI:1609176569
Name:PEDIATRIC DENTAL ASSOCIATES OF NM PC
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL ASSOCIATES OF NM PC
Other - Org Name:SMILES FOR KIDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:TASKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:505-892-9010
Mailing Address - Street 1:8501 CANDELARIA RD NE
Mailing Address - Street 2:NE SUITE D-2
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-1034
Mailing Address - Country:US
Mailing Address - Phone:505-299-9606
Mailing Address - Fax:505-299-9740
Practice Address - Street 1:8501 CANDELARIA RD NE
Practice Address - Street 2:NE SUITE D-2
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-1034
Practice Address - Country:US
Practice Address - Phone:505-299-9606
Practice Address - Fax:505-299-9740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPT01114341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty