Healthcare Provider Details

I. General information

NPI: 1760671705
Provider Name (Legal Business Name): NEW MEXICO ENDODONTIC SPECIALISTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10151 MONTGOMERY BLVD NE STE 2B
ALBUQUERQUE NM
87111-3664
US

IV. Provider business mailing address

10151 MONTGOMERY BLVD NE STE 2B
ALBUQUERQUE NM
87111-3664
US

V. Phone/Fax

Practice location:
  • Phone: 505-830-3636
  • Fax: 505-830-2305
Mailing address:
  • Phone: 505-830-3636
  • Fax: 505-830-2305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number1137
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number2173
License Number StateNM

VIII. Authorized Official

Name: DR. STEPHEN JENKINS
Title or Position: PRESIDENT
Credential: DDS
Phone: 505-830-3636