Healthcare Provider Details

I. General information

NPI: 1104942275
Provider Name (Legal Business Name): ENDODONTIC ASSOCIATES, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7520 MONTGOMERY BLVD NE BUILDING C SUITE B
ALBUQUERQUE NM
87109-1521
US

IV. Provider business mailing address

7520 MONTGOMERY BLVD NE BUILDING C, SUITE B
ALBUQUERQUE NM
87109-1521
US

V. Phone/Fax

Practice location:
  • Phone: 505-881-6902
  • Fax: 505-881-7496
Mailing address:
  • Phone: 505-881-6902
  • Fax: 505-881-7496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2728
License Number StateNM

VIII. Authorized Official

Name: DR. TERRYL ANN PETROPOULOS
Title or Position: MEMBER
Credential: D.M.D.
Phone: 505-881-6902