Provider Demographics
NPI:1285252627
Name:3501 NORTH BUTLER AVENUE FARMINGTON PROFESSIONAL LLC
Entity type:Organization
Organization Name:3501 NORTH BUTLER AVENUE FARMINGTON PROFESSIONAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUMBOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-564-4470
Mailing Address - Street 1:3501 N BUTLER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-6430
Mailing Address - Country:US
Mailing Address - Phone:505-564-4470
Mailing Address - Fax:505-325-9707
Practice Address - Street 1:3501 N BUTLER AVE STE 104
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6430
Practice Address - Country:US
Practice Address - Phone:505-564-4470
Practice Address - Fax:505-325-9707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty