Healthcare Provider Details

I. General information

NPI: 1952664039
Provider Name (Legal Business Name): JASON W SCHULTZ DMD, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 08/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 PAN AMERICAN EAST FWY NE STE 355
ALBUQUERQUE NM
87109-3460
US

IV. Provider business mailing address

6100 PAN AMERICAN EAST FWY NE STE 355
ALBUQUERQUE NM
87109-3460
US

V. Phone/Fax

Practice location:
  • Phone: 505-452-7979
  • Fax:
Mailing address:
  • Phone: 505-452-7979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberMD2019-0687
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: