Healthcare Provider Details

I. General information

NPI: 1619260502
Provider Name (Legal Business Name): GENTLE DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2011
Last Update Date: 05/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 BRIDGE BLVD SW STE E
ALBUQUERQUE NM
87105-3765
US

IV. Provider business mailing address

1010 BRIDGE BLVD SW STE E
ALBUQUERQUE NM
87105-3765
US

V. Phone/Fax

Practice location:
  • Phone: 505-877-0435
  • Fax: 505-873-8381
Mailing address:
  • Phone: 505-877-0435
  • Fax: 505-873-8381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA A DAVIS
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-877-0435