Healthcare Provider Details

I. General information

NPI: 1497848188
Provider Name (Legal Business Name): JIM R. FUQUA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ALBUQUERQUE INDIAN HEALTH SERVICE DENTAL CLINIC 9169 COORS ROAD NW
ALBUQUERQUE NM
87193
US

IV. Provider business mailing address

PO BOX 411957
MELBOURNE FL
32941-1957
US

V. Phone/Fax

Practice location:
  • Phone: 505-346-2306
  • Fax:
Mailing address:
  • Phone: 321-638-1219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3274
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: