Healthcare Provider Details

I. General information

NPI: 1437733524
Provider Name (Legal Business Name): GIOVANNI AVILA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2021
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 CENTRO FAMILIAR BLVD SW
ALBUQUERQUE NM
87105-4592
US

IV. Provider business mailing address

2001 CENTRO FAMILIAR BLVD SW
ALBUQUERQUE NM
87105-4592
US

V. Phone/Fax

Practice location:
  • Phone: 505-873-7423
  • Fax:
Mailing address:
  • Phone: 505-873-7423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDD5585
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: