# SUMMIT FAMILY DENTAL OF KIRTLAND, LLC

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

## Provider details

- **NPI number:** 1710215439
- **Authorized official:** DR. CODY B COLEMAN DDS (OWNER)
- **Authorized official phone:** (505) 598-6800

## Contact information

- **Practice address:** \#3 CR 6523, KIRTLAND, NM 87417
- **Practice address phone:** (505) 598-6800
- **Practice address fax:** (505) 598-6830
- **Mailing address:** \#3 CR 6523, KIRTLAND, NM 87417
- **Mailing address phone:** (505) 598-6800
- **Mailing address fax:** (505) 598-6830

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | DD2872 | NM | Yes |

## Other

- **Enumeration date:** 11/19/2009
- **Last updated:** 09/30/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 99183064 | — | NM |