Provider Demographics
NPI:1154624401
Name:PEDIATRIC DENTAL SPECIALIST OF NEW MEXICO LLC
Entity type:Organization
Organization Name:PEDIATRIC DENTAL SPECIALIST OF NEW MEXICO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTAL SPECIALIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:575-621-0800
Mailing Address - Street 1:5475 REMINGTON ROAD
Mailing Address - Street 2:DR. PETER HAYES
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-7594
Mailing Address - Country:US
Mailing Address - Phone:575-621-0800
Mailing Address - Fax:575-373-3091
Practice Address - Street 1:2450 SOUTH TELSHOR
Practice Address - Street 2:MEMORIAL MEDICAL HOSPITAL
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-7594
Practice Address - Country:US
Practice Address - Phone:575-621-0800
Practice Address - Fax:575-373-3091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2233122300000X
122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM92472214Medicaid