| NPI | 1790808111 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | RAYMOND EDDIE BROUSSARD Owner 505-896-0245 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: NM DD1745) |
| Enumeration Date | 2007-04-09 |
| Last Update Date | 2020-08-22 |