Healthcare Provider Details

I. General information

NPI: 1568453363
Provider Name (Legal Business Name): MITCHELL B. SILVERMAN D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8216 LOUISIANA BLVD NE
ALBUQUERQUE NM
87113-2105
US

IV. Provider business mailing address

8216 LOUISIANA BLVD NE
ALBUQUERQUE NM
87113-2105
US

V. Phone/Fax

Practice location:
  • Phone: 505-822-1234
  • Fax: 505-856-0460
Mailing address:
  • Phone: 505-822-1234
  • Fax: 505-856-0460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD2227
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: