Provider Demographics
NPI:1366931024
Name:MINERS FAMILY DENTAL, LLC
Entity type:Organization
Organization Name:MINERS FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SHRUM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:505-634-1501
Mailing Address - Street 1:PO BOX 448
Mailing Address - Street 2:
Mailing Address - City:BLANCO
Mailing Address - State:NM
Mailing Address - Zip Code:87412-0448
Mailing Address - Country:US
Mailing Address - Phone:505-634-1505
Mailing Address - Fax:
Practice Address - Street 1:1315 SNOWDEN STE. 4B
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:CO
Practice Address - Zip Code:81433
Practice Address - Country:US
Practice Address - Phone:505-634-1501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002033601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO000000Medicaid