1639537533 NPI number — LAS ESTANCIAS DENTAL GROUP, PROFESSIONAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639537533 NPI number — LAS ESTANCIAS DENTAL GROUP, PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAS ESTANCIAS DENTAL GROUP, PROFESSIONAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639537533
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17000 RED HILL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92614-5626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-845-8890
Provider Business Mailing Address Fax Number:
949-474-1495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3715 LAS ESTANCIAS WAY SW
Provider Second Line Business Practice Location Address:
101
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87121-5506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-209-9081
Provider Business Practice Location Address Fax Number:
505-792-6111
Provider Enumeration Date:
02/05/2016

Additional Information

Authorized Official

Authorized Official Last Name:
HERREJON-RUIZ
Authorized Official First Name:
MARIO
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER DENTIST
Authorized Official Telephone Number:
505-209-9081

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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