Healthcare Provider Details

I. General information

NPI: 1285179549
Provider Name (Legal Business Name): FAMILY DENTAL HEALTH CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2016
Last Update Date: 03/02/2020
Certification Date: 03/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 EUBANK BLVD SUITE 203
ALBUQUERQUE NM
87111
US

IV. Provider business mailing address

4550 EUBANK BLVD SUITE 203
ALBUQUERQUE NM
87111
US

V. Phone/Fax

Practice location:
  • Phone: 505-881-8979
  • Fax: 505-881-8979
Mailing address:
  • Phone: 505-881-8979
  • Fax: 505-881-8979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD1870
License Number StateNM

VIII. Authorized Official

Name: JENNY XAYAVONG
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-881-8979