Provider First Line Business Practice Location Address: 
608-B LA JOYA ST
    Provider Second Line Business Practice Location Address: 
EL CENTRO FAMILY HEALTH ESPANOLA DENTAL
    Provider Business Practice Location Address City Name: 
ESPANOLA
    Provider Business Practice Location Address State Name: 
NM
    Provider Business Practice Location Address Postal Code: 
87532-3467
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
505-753-9454
    Provider Business Practice Location Address Fax Number: 
505-753-0850
    Provider Enumeration Date: 
10/27/2011