Healthcare Provider Details

I. General information

NPI: 1306169529
Provider Name (Legal Business Name): ALBUQUERQUE CRANIOFACIAL CENTER, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2010
Last Update Date: 03/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7520 MONTGOMERY BLVD NE SUITE D2
ALBUQUERQUE NM
87109-1521
US

IV. Provider business mailing address

7520 MONTGOMERY BLVD NE SUITE D2
ALBUQUERQUE NM
87109-1521
US

V. Phone/Fax

Practice location:
  • Phone: 505-883-4865
  • Fax: 505-881-0113
Mailing address:
  • Phone: 505-883-4865
  • Fax: 505-881-0113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD1475
License Number StateNM

VIII. Authorized Official

Name: DR. PAUL M CLIFFORD
Title or Position: PRESIDENT
Credential: DDS
Phone: 505-883-4865