Healthcare Provider Details

I. General information

NPI: 1699099135
Provider Name (Legal Business Name): HAPPY TEETH, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2010
Last Update Date: 05/19/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10820 COMANCHE RD NE SUITE A
ALBUQUERQUE NM
87111-3983
US

IV. Provider business mailing address

10820 COMANCHE RD NE SUITE A
ALBUQUERQUE NM
87111-3983
US

V. Phone/Fax

Practice location:
  • Phone: 505-296-0761
  • Fax:
Mailing address:
  • Phone: 505-296-0761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD3190
License Number StateNM

VIII. Authorized Official

Name: DR. RUSSELL TRAPNELL
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 505-270-4544