Healthcare Provider Details

I. General information

NPI: 1518643907
Provider Name (Legal Business Name): BRIDENT DENTAL ASSOCIATES OF NEW MEXICO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 06/22/2023
Certification Date: 06/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 SAN MATEO BLVD NE STE 100
ALBUQUERQUE NM
87108-1860
US

IV. Provider business mailing address

530 S MAIN ST
ORANGE CA
92868-4525
US

V. Phone/Fax

Practice location:
  • Phone: 505-785-6754
  • Fax: 714-571-6445
Mailing address:
  • Phone: 714-480-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM DEMBERECKYJ
Title or Position: EVP, CHIEF GWTH STRGY OFFICER
Credential:
Phone: 714-571-2140