Provider Demographics
NPI:1255814968
Name:SOCORRO DENTAL CARE INC.
Entity type:Organization
Organization Name:SOCORRO DENTAL CARE INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
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:505-273-3220
Mailing Address - Fax:505-226-9697
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:87124-1860
Practice Address - Country:US
Practice Address - Phone:877-989-7413
Practice Address - Fax:505-226-9697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-09
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMDD4651OtherDENTAL LICENSE
NM90288840Medicaid