Basic Information
| Provider Information | |||||||||
| NPI: | 1841484763 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF NEW MEXICO DENTAL SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1801 CAMINO DE SALUD NE | ||||||||
| Address2: | SUITE 1200 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871020001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059257797 | ||||||||
| FaxNumber: | 5059257800 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 CAMINO DE SALUD NE | ||||||||
| Address2: | SUITE 1200 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871020001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059257797 | ||||||||
| FaxNumber: | 5059257800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2007 | ||||||||
| LastUpdateDate: | 05/08/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CUTTRELL | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF ASSISTANT PROFESSOR | ||||||||
| AuthorizedOfficialTelephone: | 5059257797 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNM MEDICAL GROUP INC. C/O REGENTS OF THE UNIVERSITY OF NEW MEXICO | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.D.S., J.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DD2136 | NM | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 28601831 | 05 | NM | MEDICAID |