Provider Demographics
NPI:1538716204
Name:DESERT PEAKS DENTAL LLC
Entity type:Organization
Organization Name:DESERT PEAKS DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLISS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:575-382-2054
Mailing Address - Street 1:810 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-2999
Mailing Address - Country:US
Mailing Address - Phone:575-524-8527
Mailing Address - Fax:
Practice Address - Street 1:810 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2999
Practice Address - Country:US
Practice Address - Phone:575-524-8527
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty