Provider Demographics
NPI:1679931356
Name:LEA COUNTY DENTAL
Entity type:Organization
Organization Name:LEA COUNTY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NISHANTH
Authorized Official - Middle Name:REDDY
Authorized Official - Last Name:PUCHALAPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:408-306-8365
Mailing Address - Street 1:701 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260-3417
Mailing Address - Country:US
Mailing Address - Phone:408-306-8365
Mailing Address - Fax:
Practice Address - Street 1:701 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:LOVINGTON
Practice Address - State:NM
Practice Address - Zip Code:88260-3417
Practice Address - Country:US
Practice Address - Phone:408-306-8365
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-09
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty