Provider Demographics
NPI:1942749775
Name:HONEST TOOTH, INC
Entity Type:Organization
Organization Name:HONEST TOOTH, INC
Other - Org Name:HONEST TOOTH FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:ALEXES
Authorized Official - Last Name:PEREYRA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-323-7966
Mailing Address - Street 1:4233 MONTGOMERY BLVD NE
Mailing Address - Street 2:SUITE 120W
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-6749
Mailing Address - Country:US
Mailing Address - Phone:505-323-7966
Mailing Address - Fax:
Practice Address - Street 1:4233 BLVD NE
Practice Address - Street 2:SUITE 120 W
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109
Practice Address - Country:US
Practice Address - Phone:505-323-7966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4062122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty