Healthcare Provider Details

I. General information

NPI: 1982148128
Provider Name (Legal Business Name): DENTAL SMILE DESIGN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2016
Last Update Date: 12/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7520 MONTGOMERY BLVD NE BLDG. C STE. D
ALBUQUERQUE NM
87109-1521
US

IV. Provider business mailing address

7520 MONTGOMERY BLVD NE BLDG. C STE. D
ALBUQUERQUE NM
87109-1521
US

V. Phone/Fax

Practice location:
  • Phone: 505-872-0327
  • Fax: 505-884-1479
Mailing address:
  • Phone: 505-872-0327
  • Fax: 505-884-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3583
License Number StateNM

VIII. Authorized Official

Name: MEAH M WASHINGTON
Title or Position: OFFICE MANAGER
Credential: OM
Phone: 505-872-0327