Provider Demographics
NPI:1982062048
Name:SANTA FE DENTIST OFFICE, LLC
Entity Type:Organization
Organization Name:SANTA FE DENTIST OFFICE, LLC
Other - Org Name:SANTA FE DENTIST OFFICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLINGSWORTH RYALS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-209-9080
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:5131 MAIN STREET
Practice Address - Street 2:101
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507
Practice Address - Country:US
Practice Address - Phone:505-209-9080
Practice Address - Fax:505-750-9982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-04
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty