Healthcare Provider Details

I. General information

NPI: 1053184440
Provider Name (Legal Business Name): PARKWAY DENTAL NM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2023
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10409 MONTGOMERY PKWY NE STE 201
ALBUQUERQUE NM
87111-3862
US

IV. Provider business mailing address

19601 N BLACK CANYON HWY # 201
PHOENIX AZ
85027-4107
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-7479
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: TERA NIEDENS
Title or Position: ACCOUNTANT
Credential:
Phone: 623-289-2616