Healthcare Provider Details

I. General information

NPI: 1639616139
Provider Name (Legal Business Name): CORNALI & MCDONALD ORTHODONTIC SPECIALITST LTD. CO.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2017
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8010 PALOMAS AVE NE SUITE A
ALBUQUERQUE NM
87109-5201
US

IV. Provider business mailing address

8010 PALOMAS AVE NE SUITE A
ALBUQUERQUE NM
87109-5201
US

V. Phone/Fax

Practice location:
  • Phone: 505-828-1244
  • Fax: 505-828-1447
Mailing address:
  • Phone: 505-828-1244
  • Fax: 505-828-1447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD4636
License Number StateNM

VIII. Authorized Official

Name: DR. ANDREW R. MCDONALD
Title or Position: OWNER
Credential: DDS
Phone: 505-828-1244