Healthcare Provider Details

I. General information

NPI: 1609170976
Provider Name (Legal Business Name): PEPPERMINT DENTAL-RIO BRAVO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2010
Last Update Date: 12/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3211 COORS BLVD SW SUITE D-2
ALBUQUERQUE NM
87121-5254
US

IV. Provider business mailing address

7301 STATE HIGHWAY 161 SUITE 198
IRVING TX
75039-2816
US

V. Phone/Fax

Practice location:
  • Phone: 972-869-3789
  • Fax:
Mailing address:
  • Phone: 972-869-3789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MARY PU
Title or Position: CFO
Credential:
Phone: 972-869-3789