Healthcare Provider Details

I. General information

NPI: 1922584663
Provider Name (Legal Business Name): PRITPAL JOHAL DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2018
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3211 COORS BLVD SW STE D2
ALBUQUERQUE NM
87121-5255
US

IV. Provider business mailing address

2300 DIAMOND MESA TRL SW APT 2703
ALBUQUERQUE NM
87121-3718
US

V. Phone/Fax

Practice location:
  • Phone: 209-765-4246
  • Fax:
Mailing address:
  • Phone: 209-765-4246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number6548
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD22006
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: