| Guadalupe Family Dental | |
|
552 Us Hwy 54 Santa Rosa NM 88435 | |
| (575) 472-2414 | |
| (575) 472-2416 |
| Full Name | Guadalupe Family Dental |
|---|---|
| Speciality | Clinic/center - Federally Qualified Health Center (fqhc) |
| Location | 552 Us Hwy 54, Santa Rosa, New Mexico |
| Authorized Official Name and Position | Lisa Walraven (CEO) |
| Authorized Official Contact | 5753552420 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Guadalupe Family Dental Po Box 349 Fort Sumner NM 88119-0349 Ph: (575) 355-2414 | Guadalupe Family Dental 552 Us Hwy 54 Santa Rosa NM 88435 Ph: (575) 472-2414 |
| NPI Number | 1962743534 |
|---|---|
| Provider Enumeration Date | 03/07/2013 |
| Last Update Date | 02/01/2018 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1962743534 | NPI | - | NPPES |
| 84331534 | Medicaid | NM |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QD0000X | Clinic/center - Dental | (New Mexico) | Secondary |
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
Deep Blue Dental Dental Clinic Medicare: Not Enrolled in Medicare Practice Location: 1000 Blue Hole Rd, Santa Rosa, NM 88435 Phone: 505-718-6899 |