Provider Demographics
NPI:1912024027
Name:NEW MEXICO DEPARTMENT OF HEALTH
Entity Type:Organization
Organization Name:NEW MEXICO DEPARTMENT OF HEALTH
Other - Org Name:NEW MEXICO DEPARTMENT OF HEALTH, SPECIAL NEEDS DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DDSD DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:COPELAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-660-3453
Mailing Address - Street 1:7905 MARBLE AVE. NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-7886
Mailing Address - Country:US
Mailing Address - Phone:505-232-5710
Mailing Address - Fax:505-232-5720
Practice Address - Street 1:7905 MARBLE AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7886
Practice Address - Country:US
Practice Address - Phone:505-232-5710
Practice Address - Fax:505-232-5720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1302122300000X
NMDD34571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM89623Medicaid