Healthcare Provider Details

I. General information

NPI: 1730248915
Provider Name (Legal Business Name): JACK RICHARD SVITZER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9169 COORS BLVD NW ALBUQUERQUE IHS DENTAL CLINIC, ORTHODONTICS
ALBUQUERQUE NM
87120-3101
US

IV. Provider business mailing address

9169 COORS BLVD NW ALBUQUERQUE IHS DENTAL CLINIC, ORTHODONTICS
ALBUQUERQUE NM
87120-3101
US

V. Phone/Fax

Practice location:
  • Phone: 505-922-4250
  • Fax: 505-346-2311
Mailing address:
  • Phone: 505-922-4250
  • Fax: 505-346-2311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4496
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: