Healthcare Provider Details

I. General information

NPI: 1144313883
Provider Name (Legal Business Name): TIMOTHY JOSE SMITH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 12/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 ENCINO PL NE STE 6
ALBUQUERQUE NM
87102-2624
US

IV. Provider business mailing address

500 BARNETT RD
BOSQUE FARMS NM
87068-8145
US

V. Phone/Fax

Practice location:
  • Phone: 505-247-8005
  • Fax: 505-843-5893
Mailing address:
  • Phone: 505-869-2307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2781
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: