Provider Demographics
NPI:1619197506
Name:NEW MEXICO DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:NEW MEXICO DEPARTMENT OF HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:PADILLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-827-0015
Mailing Address - Street 1:1190 S SAINT FRANCIS DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4173
Mailing Address - Country:US
Mailing Address - Phone:505-827-0015
Mailing Address - Fax:505-827-0021
Practice Address - Street 1:1190 S SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4173
Practice Address - Country:US
Practice Address - Phone:505-827-0015
Practice Address - Fax:505-827-0021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NME6603251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME6603Medicaid