Provider Demographics
NPI:1639537533
Name:LAS ESTANCIAS DENTAL GROUP, PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LAS ESTANCIAS DENTAL GROUP, PROFESSIONAL CORPORATION
Other - Org Name:LAS ESTANCIAS DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:HERREJON-RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:505-209-9081
Mailing Address - Street 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:3715 LAS ESTANCIAS WAY SW
Practice Address - Street 2:101
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121-5506
Practice Address - Country:US
Practice Address - Phone:505-209-9081
Practice Address - Fax:505-792-6111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty