Healthcare Provider Details

I. General information

NPI: 1629356209
Provider Name (Legal Business Name): OMNI DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7111 PROSPECT PL NE SUITE B
ALBUQUERQUE NM
87110-4309
US

IV. Provider business mailing address

7111 PROSPECT PL NE SUITE B
ALBUQUERQUE NM
87110-4309
US

V. Phone/Fax

Practice location:
  • Phone: 505-888-5131
  • Fax: 505-888-5135
Mailing address:
  • Phone: 505-888-5131
  • Fax: 505-888-5135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2344
License Number StateNM

VIII. Authorized Official

Name: DR. PE CHANG
Title or Position: CO-OWNER
Credential: D.D.S.
Phone: 505-888-5131