Provider Demographics
NPI:1508287541
Name:SANTA FE ORAL SURGERY, LLC
Entity Type:Organization
Organization Name:SANTA FE ORAL SURGERY, LLC
Other - Org Name:SANTE FE ORAL SURGERY LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS/MD
Authorized Official - Phone:505-984-0694
Mailing Address - Street 1:2100 CALLE DELA VUEILA STE B103
Mailing Address - Street 2:B103
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4749
Mailing Address - Country:US
Mailing Address - Phone:505-984-0694
Mailing Address - Fax:505-983-3270
Practice Address - Street 1:2100 CALLE DELA VUEILA STE B103
Practice Address - Street 2:B103
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4749
Practice Address - Country:US
Practice Address - Phone:505-984-0694
Practice Address - Fax:505-983-3270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-17
Last Update Date:2019-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD38861223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty