Healthcare Provider Details

I. General information

NPI: 1053780759
Provider Name (Legal Business Name): ROBERT C SUPPLE DMD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2015
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 OSUNA RD NE STE C
ALBUQUERQUE NM
87111-2074
US

IV. Provider business mailing address

8401 OSUNA RD NE STE C
ALBUQUERQUE NM
87111-2074
US

V. Phone/Fax

Practice location:
  • Phone: 505-294-8869
  • Fax: 505-292-2071
Mailing address:
  • Phone: 505-294-8869
  • Fax: 505-292-2071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1365
License Number StateNM

VIII. Authorized Official

Name: SUZY PRICE
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-294-8869