Provider Demographics
NPI:1255764650
Name:NEW MEXICO PROFESSIONAL DENTAL ASSOCIATES, INC
Entity type:Organization
Organization Name:NEW MEXICO PROFESSIONAL DENTAL ASSOCIATES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:4120 BARBARA LOOP SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1000
Mailing Address - Country:US
Mailing Address - Phone:505-892-8088
Mailing Address - Fax:
Practice Address - Street 1:4120 BARBARA LOOP SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1000
Practice Address - Country:US
Practice Address - Phone:505-892-8088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW MEXICO PROFESSIONAL DENTAL ASSOCIATES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty