Provider Demographics
NPI:1770893646
Name:CONQUISTADOR DENTAL, LLC
Entity type:Organization
Organization Name:CONQUISTADOR DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:SANCHEZ
Authorized Official - Suffix:II
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-864-7000
Mailing Address - Street 1:704 CHRISTOPHER DR
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-2629
Mailing Address - Country:US
Mailing Address - Phone:505-864-7000
Mailing Address - Fax:
Practice Address - Street 1:704 CHRISTOPHER DR
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-2629
Practice Address - Country:US
Practice Address - Phone:505-864-2055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-13
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD32851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty