Healthcare Provider Details

I. General information

NPI: 1861920696
Provider Name (Legal Business Name): COREY W. WOODS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7007 WYOMING BLVD NE STE B2
ALBUQUERQUE NM
87109-3982
US

IV. Provider business mailing address

7007 WYOMING BLVD NE STE B2
ALBUQUERQUE NM
87109-3982
US

V. Phone/Fax

Practice location:
  • Phone: 505-821-1430
  • Fax: 505-821-1442
Mailing address:
  • Phone: 505-821-1430
  • Fax: 505-821-1442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD4665
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: