| NPI | 1629164595 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JEFFREY J SUPPLE Owner 505-883-3933 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NM DD1731) |
| Enumeration Date | 2006-10-05 |
| Last Update Date | 2020-08-22 |