Healthcare Provider Details

I. General information

NPI: 1154804755
Provider Name (Legal Business Name): SJT PEDIATRIC DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4620 JEFFERSON LN NE STE C
ALBUQUERQUE NM
87109-2149
US

IV. Provider business mailing address

4620 JEFFERSON LN NE STE C
ALBUQUERQUE NM
87109-2149
US

V. Phone/Fax

Practice location:
  • Phone: 505-888-3520
  • Fax:
Mailing address:
  • Phone: 505-850-3769
  • Fax: 505-890-2949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: EBONIE GONZALES
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 505-850-3769