Provider Demographics
NPI:1013404581
Name:NEW MEXICO DENTAL CLINICS LLC
Entity Type:Organization
Organization Name:NEW MEXICO DENTAL CLINICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:HANNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-273-3220
Mailing Address - Street 1:1594 SARA RD SE STE C
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1860
Mailing Address - Country:US
Mailing Address - Phone:866-851-6236
Mailing Address - Fax:
Practice Address - Street 1:1594 SARA RD SE STE C
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124
Practice Address - Country:US
Practice Address - Phone:866-851-6236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-19
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD46511223G0001X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMDD4651OtherDENTAL LICENSE