Provider Demographics
NPI:1760400998
Name:PECK, PATRICIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:
Last Name:PECK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1692 HOSPITAL DR BLDG B
Mailing Address - Street 2:STE 102
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4754
Mailing Address - Country:US
Mailing Address - Phone:505-989-9033
Mailing Address - Fax:505-989-9347
Practice Address - Street 1:1692 HOSPITAL DR BLDG B
Practice Address - Street 2:STE 102
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4754
Practice Address - Country:US
Practice Address - Phone:505-989-9033
Practice Address - Fax:505-989-9347
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD16721223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM85-0477522OtherDELTA DENTAL INS
NM0009630Medicaid
NM1320507OtherUNITED CONCORDIA INS