Healthcare Provider Details

I. General information

NPI: 1518216746
Provider Name (Legal Business Name): DUKE CITY PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2012
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8220 LOUISIANA BLVD NE SUITE A
ALBUQUERQUE NM
87113
US

IV. Provider business mailing address

8220 LOUISIANA BLVD NE SUITE A
ALBUQUERQUE NM
87113
US

V. Phone/Fax

Practice location:
  • Phone: 303-868-6117
  • Fax: 505-369-1828
Mailing address:
  • Phone: 303-868-6117
  • Fax: 505-369-1828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDD3279
License Number StateNM

VIII. Authorized Official

Name: DR. TAMERA PAGE COFFMAN
Title or Position: OWNER DENTIST
Credential: DDS
Phone: 505-433-3366