Provider Demographics
NPI:1033708235
Name:PROFESSIONAL DENTAL CARE OF NORTHERN NEW MEXICO III
Entity type:Organization
Organization Name:PROFESSIONAL DENTAL CARE OF NORTHERN NEW MEXICO III
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CARY
Authorized Official - Middle Name:
Authorized Official - Last Name:LACOUTURE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:303-521-5701
Mailing Address - Street 1:10233 S PARKER RD STE 107
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-9314
Mailing Address - Country:US
Mailing Address - Phone:303-521-5701
Mailing Address - Fax:
Practice Address - Street 1:2500 7TH ST STE H
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4947
Practice Address - Country:US
Practice Address - Phone:505-718-9156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSUN HEALTH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty