Healthcare Provider Details

I. General information

NPI: 1821179508
Provider Name (Legal Business Name): GERALD FRANK PROHASKA DDS,MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 MONTGOMERY BLVD NE SUITE B
ALBUQUERQUE NM
87109-1405
US

IV. Provider business mailing address

6800 MONTGOMERY BLVD NE SUITE B
ALBUQUERQUE NM
87109-1405
US

V. Phone/Fax

Practice location:
  • Phone: 505-881-1100
  • Fax: 505-884-2933
Mailing address:
  • Phone: 505-881-1100
  • Fax: 505-884-2933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number826
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: