Healthcare Provider Details

I. General information

NPI: 1427379130
Provider Name (Legal Business Name): DANEN SJOSTROM DDS, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2010
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7007 WYOMING BLVD NE SUITE C-2
ALBUQUERQUE NM
87109-3987
US

IV. Provider business mailing address

7007 WYOMING BLVD NE SUITE C-2
ALBUQUERQUE NM
87109-3987
US

V. Phone/Fax

Practice location:
  • Phone: 614-949-9685
  • Fax:
Mailing address:
  • Phone: 614-949-9685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDD3647
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: