Healthcare Provider Details

I. General information

NPI: 1457527368
Provider Name (Legal Business Name): SOUTHWEST ORAL & MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 12/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 CUBERO DR NE STE A
ALBUQUERQUE NM
87109-3879
US

IV. Provider business mailing address

5900 CUBERO DR NE STE A
ALBUQUERQUE NM
87109-3879
US

V. Phone/Fax

Practice location:
  • Phone: 505-797-3530
  • Fax: 505-797-2155
Mailing address:
  • Phone: 505-797-3530
  • Fax: 505-797-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDD1094
License Number StateNM

VIII. Authorized Official

Name: DR. JERRY L JONES
Title or Position: OWNER
Credential: M.D.,D.D.S.
Phone: 505-797-3530