Basic Information
| Provider Information | |||||||||
| NPI: | 1821430968 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ENCHANTED SMILES | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 305 RIO COMMUNITIES BLVD | ||||||||
| Address2: | |||||||||
| City: | BELEN | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870026168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058642978 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 305 RIO COMMUNITIES BLVD | ||||||||
| Address2: | |||||||||
| City: | BELEN | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870026168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058642978 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2013 | ||||||||
| LastUpdateDate: | 07/17/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MONTOYA | ||||||||
| AuthorizedOfficialFirstName: | DEANNA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5055508291 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RDH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | DH1276 | NM | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dental Hygienist |
No ID Information.