Healthcare Provider Details

I. General information

NPI: 1396127619
Provider Name (Legal Business Name): JESSE VAROZ DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2015
Last Update Date: 06/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10409 MONTGOMERY PKWY NE SUITE 201
ALBUQUERQUE NM
87111-3852
US

IV. Provider business mailing address

10409 MONTGOMERY PKWY NE SUITE 201
ALBUQUERQUE NM
87111-3852
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-7479
  • Fax:
Mailing address:
  • Phone: 505-298-7479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD4315
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: