Provider Demographics
NPI:1912064767
Name:PINON HILLS DENTAL
Entity Type:Organization
Organization Name:PINON HILLS DENTAL
Other - Org Name:HARVEY R. WEBER DDS PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-325-2859
Mailing Address - Street 1:4725 FOOTHILLS DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402
Mailing Address - Country:US
Mailing Address - Phone:505-325-2859
Mailing Address - Fax:505-325-1130
Practice Address - Street 1:4725 FOOTHILLS DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402
Practice Address - Country:US
Practice Address - Phone:505-325-2859
Practice Address - Fax:505-325-1130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM10861223G0001X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty