Healthcare Provider Details

I. General information

NPI: 1629615851
Provider Name (Legal Business Name): SOUTHWEST ORAL AND MAXILLOFACIAL SURGEONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2019
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 CUBERO DR NE STE A
ALBUQUERQUE NM
87109-3879
US

IV. Provider business mailing address

5900 CUBERO DR NE STE A
ALBUQUERQUE NM
87109-3879
US

V. Phone/Fax

Practice location:
  • Phone: 505-797-3530
  • Fax: 505-797-2155
Mailing address:
  • Phone: 505-797-3530
  • Fax: 505-797-2155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WAI PONG NG
Title or Position: OWNER
Credential: DMD
Phone: 505-797-3530