Healthcare Provider Details

I. General information

NPI: 1104930288
Provider Name (Legal Business Name): JEFFERY BRYAN WHEATON DDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1628 ALAMEDA BLVD NW
ALBUQUERQUE NM
87114
US

IV. Provider business mailing address

1628 ALAMEDA BLVD NW
ALBUQUERQUE NM
87114
US

V. Phone/Fax

Practice location:
  • Phone: 505-899-6979
  • Fax: 505-899-6980
Mailing address:
  • Phone: 505-899-6979
  • Fax: 505-899-6980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDDS 2052
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: