Provider Demographics
NPI:1801963939
Name:FARMINGTON ORAL & MAXILLOFACIAL SURGICAL CLINIC
Entity type:Organization
Organization Name:FARMINGTON ORAL & MAXILLOFACIAL SURGICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:J
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-598-9085
Mailing Address - Street 1:PO BOX 2872
Mailing Address - Street 2:SURGICAL CLINIC INC
Mailing Address - City:KIRTLAND
Mailing Address - State:NM
Mailing Address - Zip Code:87417-2872
Mailing Address - Country:US
Mailing Address - Phone:505-598-9085
Mailing Address - Fax:505-598-1156
Practice Address - Street 1:20 CR 6070
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401
Practice Address - Country:US
Practice Address - Phone:505-590-9085
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNMDD19311223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty