Provider Demographics
NPI:1811009855
Name:PEARLY WHITES DENTAL OFFICE, INC.
Entity Type:Organization
Organization Name:PEARLY WHITES DENTAL OFFICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PROFAZI
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:505-891-1500
Mailing Address - Street 1:PO BOX 15256
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87174-0256
Mailing Address - Country:US
Mailing Address - Phone:505-891-1500
Mailing Address - Fax:505-891-8400
Practice Address - Street 1:4041 BARBARA LOOP SE
Practice Address - Street 2:SUITE A
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1065
Practice Address - Country:US
Practice Address - Phone:505-891-1500
Practice Address - Fax:505-891-8400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1948122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty