Healthcare Provider Details

I. General information

NPI: 1063989622
Provider Name (Legal Business Name): DENTAL HOUSE GOLF COURSE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2018
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8521 GOLF COURSE RD NW STE 116
ALBUQUERQUE NM
87114-4549
US

IV. Provider business mailing address

8521 GOLF COURSE RD NW STE 116
ALBUQUERQUE NM
87114-4549
US

V. Phone/Fax

Practice location:
  • Phone: 505-897-6453
  • Fax: 505-897-8027
Mailing address:
  • Phone: 505-897-6453
  • Fax: 505-897-8027

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: MR. DOUGLAS LEE
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 505-615-4332