Healthcare Provider Details

I. General information

NPI: 1750359618
Provider Name (Legal Business Name): LIONEL MICHAEL CANDELARIA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7308 WADI MUSA DR NE
ALBUQUERQUE NM
87122-3346
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 505-321-8291
  • Fax:
Mailing address:
  • Phone: 505-881-1130
  • Fax: 505-881-2081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDD1894
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: