Healthcare Provider Details

I. General information

NPI: 1831241645
Provider Name (Legal Business Name): MICHAEL S SPARKS DDS.,MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10425 MONTGOMERY PKWY NE
ALBUQUERQUE NM
87111-3864
US

IV. Provider business mailing address

10425 MONTGOMERY PKWY NE
ALBUQUERQUE NM
87111-3864
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-9000
  • Fax: 505-294-3998
Mailing address:
  • Phone: 505-291-9000
  • Fax: 505-294-3998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2729
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: