Provider Demographics
NPI:1619666732
Name:ANIMAS PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:ANIMAS PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JENS
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:435-459-4457
Mailing Address - Street 1:2650 E PINON FRONTAGE RD BLDG 200
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-5084
Mailing Address - Country:US
Mailing Address - Phone:505-599-9359
Mailing Address - Fax:
Practice Address - Street 1:2650 E PINON FRONTAGE RD BLDG 200
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-5084
Practice Address - Country:US
Practice Address - Phone:505-599-9359
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-04
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty