Provider Demographics
NPI:1396174116
Name:UNIVERSITY FAMILY DENTAL PC
Entity type:Organization
Organization Name:UNIVERSITY FAMILY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:H
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:575-521-0127
Mailing Address - Street 1:705 E UNIVERSITY AVE STE B
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-5637
Mailing Address - Country:US
Mailing Address - Phone:575-521-0127
Mailing Address - Fax:575-647-9533
Practice Address - Street 1:705 E UNIVERSITY AVE STE B
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-5637
Practice Address - Country:US
Practice Address - Phone:575-521-0127
Practice Address - Fax:575-647-9533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-02
Last Update Date:2013-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2498122300000X
NM2317122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty