# CLOVIS HOSPITAL DENTISTRY PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1083968077
- **Authorized official:** FALON WAISATH D.M.D. (PRESIDENT)
- **Authorized official phone:** (575) 763-9382

## Contact information

- **Practice address:** 2100 N MARTIN LUTHER KING JR. BLVD, CLOVIS, NM 88101
- **Practice address phone:** (575) 763-9382
- **Mailing address:** 1552 BOSC CT, CLOVIS, NM 88101-2334
- **Mailing address phone:** (575) 763-9382

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | DD3553 | NM | Yes |

## Other

- **Enumeration date:** 10/30/2012
- **Last updated:** 10/30/2012