Provider Demographics
NPI:1609832740
Name:SAMANIEGO, MARIO J (DDS)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:J
Last Name:SAMANIEGO
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 1:2569 E IDAHO AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4578
Mailing Address - Country:US
Mailing Address - Phone:505-523-1479
Mailing Address - Fax:505-523-2974
Practice Address - Street 1:2569 E IDAHO AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4578
Practice Address - Country:US
Practice Address - Phone:505-523-1479
Practice Address - Fax:505-523-2974
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM15151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice