Healthcare Provider Details

I. General information

NPI: 1396865267
Provider Name (Legal Business Name): NEW MEXICO CENTER FOR CRANIOFACIAL PAIN,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7111 PROSPECT PL NE SUITE D-301
ALBUQUERQUE NM
87110-4309
US

IV. Provider business mailing address

7111 PROSPECT PL NE SUITE D-301
ALBUQUERQUE NM
87110-4309
US

V. Phone/Fax

Practice location:
  • Phone: 505-883-6446
  • Fax:
Mailing address:
  • Phone: 505-883-6446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD664
License Number StateNM

VIII. Authorized Official

Name: BEN J. BRABB
Title or Position: MANAGER
Credential: DDS
Phone: 505-883-6446