Healthcare Provider Details

I. General information

NPI: 1689876963
Provider Name (Legal Business Name): ORAL AND MAXILLOFACIAL SURGERY ASSOCIATE OF NEW MEXICO, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 07/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 MONTGOMERY BLVD NE SUITE A
ALBUQUERQUE NM
87109-1405
US

IV. Provider business mailing address

6800 MONTGOMERY BLVD NE SUITE A
ALBUQUERQUE NM
87109-1405
US

V. Phone/Fax

Practice location:
  • Phone: 505-881-1130
  • Fax:
Mailing address:
  • Phone: 505-881-1130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number02-256180-00-3
License Number StateNM

VIII. Authorized Official

Name: JOHN C MITCHELL
Title or Position: MANAGING PARTNER
Credential: D.D.S.
Phone: 505-881-1130