Provider Demographics
NPI:1679872378
Name:MOUNTAIN DENTAL OF NEW MEXICO PC
Entity Type:Organization
Organization Name:MOUNTAIN DENTAL OF NEW MEXICO PC
Other - Org Name:MOUNTAIN DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:MOOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-926-5050
Mailing Address - Street 1:680 HEHLI WAY
Mailing Address - Street 2:
Mailing Address - City:MONDOVI
Mailing Address - State:WI
Mailing Address - Zip Code:54755-1639
Mailing Address - Country:US
Mailing Address - Phone:715-926-5050
Mailing Address - Fax:715-926-5405
Practice Address - Street 1:680 HEHLI WAY
Practice Address - Street 2:
Practice Address - City:MONDOVI
Practice Address - State:WI
Practice Address - Zip Code:54755-1639
Practice Address - Country:US
Practice Address - Phone:715-926-5050
Practice Address - Fax:715-926-5405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-21
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD32631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty