Provider Demographics
NPI:1174956676
Name:SOUTHERN NEW MEXICO DENTAL GROUP PC
Entity type:Organization
Organization Name:SOUTHERN NEW MEXICO DENTAL GROUP PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:BOBBY
Authorized Official - Last Name:ESPINEZA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:575-382-2054
Mailing Address - Street 1:2455 S. TELSHOR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011
Mailing Address - Country:US
Mailing Address - Phone:575-522-0454
Mailing Address - Fax:575-522-3472
Practice Address - Street 1:2455 S. TELSHOR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011
Practice Address - Country:US
Practice Address - Phone:575-522-0454
Practice Address - Fax:575-522-3472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD34621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty