Healthcare Provider Details

I. General information

NPI: 1659460137
Provider Name (Legal Business Name): MECKLER PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 CARMEL AVE NE SUITE 602
ALBUQUERQUE NM
87122-3147
US

IV. Provider business mailing address

8300 CARMEL AVE NE SUITE 602
ALBUQUERQUE NM
87122-3147
US

V. Phone/Fax

Practice location:
  • Phone: 505-878-0700
  • Fax: 505-880-1020
Mailing address:
  • Phone: 505-878-0700
  • Fax: 505-880-1020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDD1838
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDD1993
License Number StateNM

VIII. Authorized Official

Name: DR. JOSEPH B. MECKLER
Title or Position: PRESIDENT
Credential: DDS
Phone: 505-878-0700