Provider Demographics
NPI:1710052543
Name:MAIN STREET DENTISTRY
Entity Type:Organization
Organization Name:MAIN STREET DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:UILKIE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-865-3395
Mailing Address - Street 1:705 MAIN ST SW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-8308
Mailing Address - Country:US
Mailing Address - Phone:505-865-3395
Mailing Address - Fax:505-865-1414
Practice Address - Street 1:705 MAIN ST SW
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-8308
Practice Address - Country:US
Practice Address - Phone:505-865-3395
Practice Address - Fax:505-865-1414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental