Healthcare Provider Details

I. General information

NPI: 1912024027
Provider Name (Legal Business Name): NEW MEXICO DEPARTMENT OF HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 07/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7905 MARBLE AVE NE
ALBUQUERQUE NM
87110-7886
US

IV. Provider business mailing address

7905 MARBLE AVE. NE
ALBUQUERQUE NM
87110-7886
US

V. Phone/Fax

Practice location:
  • Phone: 505-232-5710
  • Fax: 505-232-5720
Mailing address:
  • Phone: 505-232-5710
  • Fax: 505-232-5720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD1302
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD3457
License Number StateNM

VIII. Authorized Official

Name: MR. JIM COPELAND
Title or Position: DDSD DIRECTOR
Credential:
Phone: 505-660-3453