Healthcare Provider Details

I. General information

NPI: 1639397854
Provider Name (Legal Business Name): ORTHODONTIC SPECIALISTS OF ALBUQUERQUE SANTA FE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 08/22/2020
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:
Mailing address:
  • Phone: 505-822-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberDD2277
License Number StateNM

VIII. Authorized Official

Name: DR. MITCHELL B SILVERMAN
Title or Position: ORTHODONTIST
Credential: DMD
Phone: 505-822-1234