Provider Demographics
NPI:1942636113
Name:SONOMA FAMILY DENTAL, LLC
Entity Type:Organization
Organization Name:SONOMA FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CORY
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:575-522-0454
Mailing Address - Street 1:3340 RINCONADA BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011
Mailing Address - Country:US
Mailing Address - Phone:575-522-0454
Mailing Address - Fax:
Practice Address - Street 1:3015 HILLRISE DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4703
Practice Address - Country:US
Practice Address - Phone:575-522-0454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD34621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty