Provider Demographics
NPI:1679108815
Name:BELEN FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:BELEN FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAYSON
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA-GURULE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-615-2999
Mailing Address - Street 1:1501 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-7429
Mailing Address - Country:US
Mailing Address - Phone:505-864-6969
Mailing Address - Fax:505-864-9310
Practice Address - Street 1:1501 E RIVER RD
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-7429
Practice Address - Country:US
Practice Address - Phone:505-864-6969
Practice Address - Fax:505-864-9310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM73150037Medicaid