Healthcare Provider Details

I. General information

NPI: 1083022263
Provider Name (Legal Business Name): DEMING CHILDREN'S DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 07/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8201 GOLFCOURSE RD NW C-3
ALBUQUERQUE NM
87120
US

IV. Provider business mailing address

8201 GOLF COURSE RD NW STE C3
ALBUQUERQUE NM
87120-5805
US

V. Phone/Fax

Practice location:
  • Phone: 505-892-9010
  • Fax: 505-899-4804
Mailing address:
  • Phone: 505-892-9010
  • Fax: 505-899-4804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD4143
License Number StateNM

VIII. Authorized Official

Name: DR. KYE GRANT KINZER
Title or Position: DENTIST
Credential: DDS
Phone: 505-892-9010