SUMMIT FAMILY DENTAL OF BERNALILLO, LLC

NPI: 1346833878 · RIO RANCHO, NM 87144 · Dental Clinic/Center · NPI assigned 02/16/2021

$17K

Total Medicaid Paid

644

Total Claims

635

Beneficiaries

Codes Billed

2021-07

First Month

2024-06

Last Month

Provider Details

Authorized Official	HODGES, LISA (OPERATIONS DIRECTOR)
NPI Enumeration Date	02/16/2021

Other providers sharing the same authorized official: HODGES, LISA

Provider	City	State	Total Paid
BECKLAND DENTAL KIDS OF FARMINGTON LLC	FARMINGTON	NM	$4.29M
SUMMIT FAMILY DENTAL OF FARMINGTON, LLC	FARMINGTON	NM	$812K
SUMMIT FAMILY DENTAL OF CORTEZ, PLLC	CORTEZ	CO	$302K
SUNDANCE ORTHODONTICS LLC	FARMINGTON	NM	$192K

Code	Description	Claims	Beneficiaries	Total Paid
D1110	Prophylaxis - adult	122	122	$4K
D0274	Bitewings - four radiographic images	113	113	$3K
D0150	Comprehensive oral evaluation - new or established patient	66	66	$2K
D1206	Topical application of fluoride varnish	109	109	$2K
D1120	Prophylaxis - child	57	57	$2K
D0120	Periodic oral evaluation - established patient	57	56	$1K
D2391	Resin-based composite - one surface, posterior, primary or permanent	20	12	$989.56
D0220	Intraoral - periapical first radiographic image	59	59	$588.75
D0230	Intraoral - periapical each additional radiographic image	41	41	$354.33