Provider Demographics
NPI:1063989622
Name:DENTAL HOUSE GOLF COURSE, LLC
Entity type:Organization
Organization Name:DENTAL HOUSE GOLF COURSE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-615-4332
Mailing Address - Street 1:8521 GOLF COURSE RD NW STE 116
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4549
Mailing Address - Country:US
Mailing Address - Phone:505-897-6453
Mailing Address - Fax:505-897-8027
Practice Address - Street 1:8521 GOLF COURSE RD NW STE 116
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-4549
Practice Address - Country:US
Practice Address - Phone:505-897-6453
Practice Address - Fax:505-897-8027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-31
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental