MEDICARE: ABQ MODERN DENTAL GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1326429622
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABQ MODERN DENTAL GROUP, LLC

Provider Business Mailing Address
First Line	:	17000 RED HILL AVE
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92614-5626
Country	:	US
Telephone Number	:	714-845-8890
Fax Number	:	949-474-1495

Provider Business Practice Location Address
First Line	:	12611 MONTGOMERY BLVD NE
Second Line	:	A-1
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87111-4118
Country	:	US
Telephone Number	:	505-323-1004
Fax Number	:	505-323-4355

Authorized Official
Title or Position	:	OWNER DENTIST
Name	:	KELLEY HOLLINGSWORTH RYALS
Credential	:	DDS
Telephone Number	:	505-323-1004

Provider Enumeration Date	:	06/11/2015
Last Update Date	:	06/11/2015

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