Provider Demographics
NPI:1922831551
Name:DACC DENTAL CLINIC
Entity type:Organization
Organization Name:DACC DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEPARTMENT CHAIR
Authorized Official - Prefix:DR
Authorized Official - First Name:ELMER
Authorized Official - Middle Name:ELEAZAR
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:575-528-7216
Mailing Address - Street 1:3400 S ESPINA ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88003-1290
Mailing Address - Country:US
Mailing Address - Phone:575-528-7071
Mailing Address - Fax:
Practice Address - Street 1:3400 S ESPINA ST RM 80
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88003-1290
Practice Address - Country:US
Practice Address - Phone:575-528-7071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW MEXICO STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental