Healthcare Provider Details

I. General information

NPI: 1134590722
Provider Name (Legal Business Name): TRUCARE DENTAL WYOMING BLVD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2015
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 WYOMING BLVD NE STE A
ALBUQUERQUE NM
87112-3866
US

IV. Provider business mailing address

1510 WYOMING BLVD NE STE A
ALBUQUERQUE NM
87112-3866
US

V. Phone/Fax

Practice location:
  • Phone: 505-369-0074
  • Fax:
Mailing address:
  • Phone: 505-369-0074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD3577
License Number StateNM

VIII. Authorized Official

Name: ANDREA PATTERSON
Title or Position: PRESIDENT
Credential: DDS
Phone: 505-369-0074