Healthcare Provider Details

I. General information

NPI: 1275964587
Provider Name (Legal Business Name): IVORY DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 12/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5920 WHITEMAN DR NW
ALBUQUERQUE NM
87120
US

IV. Provider business mailing address

5920 WHITEMAN DR NW
ALBUQUERQUE NM
87120-2198
US

V. Phone/Fax

Practice location:
  • Phone: 505-897-6889
  • Fax: 505-922-1319
Mailing address:
  • Phone: 505-897-6889
  • Fax: 505-922-1319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD4010
License Number StateNM

VIII. Authorized Official

Name: DR. BRENDON E PRESTWICH
Title or Position: DENTIST
Credential: DDS
Phone: 505-897-6889