Healthcare Provider Details

I. General information

NPI: 1316455017
Provider Name (Legal Business Name): PINO PERIODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 01/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7007 WYOMING BLVD NE STE D1
ALBUQUERQUE NM
87109-3981
US

IV. Provider business mailing address

PO BOX 94598
ALBUQUERQUE NM
87199-4598
US

V. Phone/Fax

Practice location:
  • Phone: 505-822-0565
  • Fax: 505-821-4242
Mailing address:
  • Phone: 505-822-0565
  • Fax: 505-821-4242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: REBECCA A PINO
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-822-0565