Provider Demographics
NPI:1063989531
Name:DR. JACK O. SMALLEY DSS
Entity type:Organization
Organization Name:DR. JACK O. SMALLEY DSS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEANZA
Authorized Official - Middle Name:D
Authorized Official - Last Name:SONA
Authorized Official - Suffix:
Authorized Official - Credentials:RDA
Authorized Official - Phone:505-327-3331
Mailing Address - Street 1:2650 E PINON FRONTAGE RD BLDG 300
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-5084
Mailing Address - Country:US
Mailing Address - Phone:505-327-3331
Mailing Address - Fax:505-327-0873
Practice Address - Street 1:2650 E PINON FRONTAGE RD BLDG 300
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-5084
Practice Address - Country:US
Practice Address - Phone:505-327-3331
Practice Address - Fax:505-327-0873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-01
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM84279826Medicaid