Healthcare Provider Details

I. General information

NPI: 1295277903
Provider Name (Legal Business Name): LEGACY DENTAL PARTNERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2016
Last Update Date: 11/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5343 WYOMING BLVD NE STE A
ALBUQUERQUE NM
87109-3199
US

IV. Provider business mailing address

5343 WYOMING BLVD NE STE A
ALBUQUERQUE NM
87109-3199
US

V. Phone/Fax

Practice location:
  • Phone: 505-822-8777
  • Fax:
Mailing address:
  • Phone: 505-822-8777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD3103
License Number StateNM

VIII. Authorized Official

Name: DR. STEWART ANDERSON
Title or Position: PARTNER
Credential: DMD
Phone: 505-314-6526