Healthcare Provider Details

I. General information

NPI: 1043487119
Provider Name (Legal Business Name): COTTONWOOD MALL DENTAL PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 COORS BYP NW # G-218
ALBUQUERQUE NM
87114-4040
US

IV. Provider business mailing address

10000 COORS BYP NW # G-218
ALBUQUERQUE NM
87114-4040
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-4867
  • Fax: 505-890-2883
Mailing address:
  • Phone: 505-242-4867
  • Fax: 505-890-2883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM A. SAPP
Title or Position: PRESIDENT
Credential: DDS
Phone: 505-242-4867