Healthcare Provider Details

I. General information

NPI: 1497960561
Provider Name (Legal Business Name): BONGMIN AN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 02/18/2026
Certification Date: 02/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3211 COORS BLVD SW STE D2
ALBUQUERQUE NM
87121-5255
US

IV. Provider business mailing address

6205 CASA BLANCA NW
ALBUQUERQUE NM
87120-3280
US

V. Phone/Fax

Practice location:
  • Phone: 505-336-7451
  • Fax:
Mailing address:
  • Phone: 541-301-7609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD5580
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: