Provider Demographics
NPI:1679017453
Name:EMBUDO DENTAL CENTER LLC
Entity Type:Organization
Organization Name:EMBUDO DENTAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-579-4680
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:1102 STATE HIGHWAY 68
Mailing Address - City:EMBUDO
Mailing Address - State:NM
Mailing Address - Zip Code:87531-0037
Mailing Address - Country:US
Mailing Address - Phone:505-579-4680
Mailing Address - Fax:505-579-4074
Practice Address - Street 1:1102 STATE HIGHWAY 68
Practice Address - Street 2:
Practice Address - City:EMBUDO
Practice Address - State:NM
Practice Address - Zip Code:87531-0037
Practice Address - Country:US
Practice Address - Phone:505-579-4680
Practice Address - Fax:505-579-4074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1953261QD0000X
NMDD1074261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental