Healthcare Provider Details

I. General information

NPI: 1699183483
Provider Name (Legal Business Name): DENNIS BETDANIEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2014
Last Update Date: 07/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 EUBANK BLVD NE
ALBUQUERQUE NM
87123-2758
US

IV. Provider business mailing address

400 EUBANK BLVD NE
ALBUQUERQUE NM
87123-2758
US

V. Phone/Fax

Practice location:
  • Phone: 505-292-8035
  • Fax:
Mailing address:
  • Phone: 505-292-8035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number4936
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: