Healthcare Provider Details

I. General information

NPI: 1013390087
Provider Name (Legal Business Name): CRDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 07/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 COORS BLVD NW STE A
ALBUQUERQUE NM
87120-1204
US

IV. Provider business mailing address

2800 COORS BLVD NW STE A
ALBUQUERQUE NM
87120-1204
US

V. Phone/Fax

Practice location:
  • Phone: 505-350-1166
  • Fax: 505-352-2805
Mailing address:
  • Phone: 505-350-1166
  • Fax: 505-352-2805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD4332
License Number StateNM

VIII. Authorized Official

Name: DR. MICHAEL ROSS CONNER
Title or Position: DENTIST
Credential: DDS
Phone: 575-642-4779