Healthcare Provider Details

I. General information

NPI: 1053901447
Provider Name (Legal Business Name): SANDIA PEAK DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2021
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 EUBANK BLVD NE
ALBUQUERQUE NM
87122-3225
US

IV. Provider business mailing address

8000 EUBANK BLVD NE
ALBUQUERQUE NM
87122-3225
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-6732
  • Fax: 505-275-9976
Mailing address:
  • Phone: 505-298-6732
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JANSEN DONOGHUE
Title or Position: MEMBER
Credential:
Phone: 505-298-6732