DE BACA FAMILY PRACTICE CLINIC NPI 1962743534

NPI Information

NPI: 1962743534
Provider Name: DE BACA FAMILY PRACTICE CLINIC
Classification: Clinic/Center - 261QF0400X
Specialization: Federally Qualified Health Center (FQHC)
Entity Type: Organization
Doing Business As: GUADALUPE FAMILY DENTAL
CLIA Number: 32D0537331
Address: 552 US HWY 54
SANTA ROSA, NM
ZIP 88435
Phone: (575) 472-2414

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NPI Details

DE BACA FAMILY PRACTICE CLINIC is a federally qualified health center (fqhc) clinic center in Santa Rosa, NM. DE BACA FAMILY PRACTICE CLINIC NPI is 1962743534. The provider is registered as an organization entity type.
The provider Is Doing Business As Guadalupe Family Dental.

The provider's business location address is:

552 US HWY 54
SANTA ROSA, NM
ZIP 88435
Phone: (575) 472-2414
Fax: (575) 472-2416

The provider's authorized official is Lisa Walraven .
The authorized official title is Ceo and has the following contact phone number (575) 355-2420.

The CLIA number assigned to this NPI record is 32D0537331 - federally qualified health center with a certificate type of Certificate of Compliance.

The enumeration date for this NPI number is 3/7/2013 and was last updated on 2/1/2018.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No.	Taxonomy Code	Taxonomy Clasification	Taxonomy Specialization	License Number	License State	Primary
1	261QD0000X	Clinic/Center	Dental		NEW MEXICO	No
2	261QF0400X	Clinic/Center	Federally Qualified Health Center (FQHC)			Yes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No.	Other Provider Identifier	Other Provider Identifier Type	Other Provider Identifier State	Other Provider Identifier Issuer
1	84331534	MEDICAID	NEW MEXICO

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 11/21/2025

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