Healthcare Provider Details

I. General information

NPI: 1386868321
Provider Name (Legal Business Name): WESTSIDE FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 08/22/2020
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
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 Number2025
License Number State

VIII. Authorized Official

Name: MS. ANNA G DELAO
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-897-6889