Healthcare Provider Details

I. General information

NPI: 1598929242
Provider Name (Legal Business Name): WEST MESA ORAL AND MAXILLOFACIAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 07/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 MCMAHON BLVD NW STE 230
ALBUQUERQUE NM
87114-5478
US

IV. Provider business mailing address

4801 MCMAHON BLVD NW STE 230
ALBUQUERQUE NM
87114-5478
US

V. Phone/Fax

Practice location:
  • Phone: 505-792-4788
  • Fax: 505-792-2533
Mailing address:
  • Phone: 505-792-4788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDD1819
License Number StateNM

VIII. Authorized Official

Name: MRS. SHANNON ROYBAL
Title or Position: ACCOUNTS RECEIVABLE
Credential:
Phone: 505-792-4788