Provider Demographics
NPI:1750484853
Name:DENTAL ASSOCIATES PA
Entity Type:Organization
Organization Name:DENTAL ASSOCIATES PA
Other - Org Name:DENTAL ASSOCIATES PA
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:SUDIMACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:575-522-7320
Mailing Address - Street 1:2205 S SOLANO DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001
Mailing Address - Country:US
Mailing Address - Phone:505-522-7320
Mailing Address - Fax:505-522-6395
Practice Address - Street 1:2205 S SOLANO DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001
Practice Address - Country:US
Practice Address - Phone:505-522-7320
Practice Address - Fax:505-522-6395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM15181223G0001X
NMNM22581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM8403OtherBLUE CROSS BLUE SHIELD
806920OtherUNITED CONCORDIA INS