Provider Demographics
NPI:1801286299
Name:CABEZON PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:CABEZON PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SPENCER
Authorized Official - Middle Name:J
Authorized Official - Last Name:TASKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:505-884-5437
Mailing Address - Street 1:2421 CABEZON BLVD SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1515
Mailing Address - Country:US
Mailing Address - Phone:505-884-5437
Mailing Address - Fax:
Practice Address - Street 1:2421 CABEZON BLVD SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1515
Practice Address - Country:US
Practice Address - Phone:505-884-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-23
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMD2829261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental