Healthcare Provider Details

I. General information

NPI: 1972052652
Provider Name (Legal Business Name): ABQ DENTURES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2016
Last Update Date: 09/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010-K WYOMING BLVD. NE
ALBUQUERQUE NM
87112-2678
US

IV. Provider business mailing address

2010-K WYOMING BLVD. NE
ALBUQUERQUE NM
87112-2678
US

V. Phone/Fax

Practice location:
  • Phone: 505-344-4948
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD3069
License Number StateNM

VIII. Authorized Official

Name: DR. PETER ROUKEMA
Title or Position: MEMBER
Credential: DMD
Phone: 216-374-5693