Healthcare Provider Details

I. General information

NPI: 1497008312
Provider Name (Legal Business Name): SANDIA PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2012
Last Update Date: 10/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 505-200-3516
  • Fax:
Mailing address:
  • Phone: 505-200-3516
  • 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: DR. DANEN SCOTT SJOSTROM
Title or Position: PEDIATRIC DENTIST
Credential: DDS, PH.D
Phone: 614-949-9685