Healthcare Provider Details

I. General information

NPI: 1184435521
Provider Name (Legal Business Name): FC 120 98TH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 01/24/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 98TH ST NW STE C3
ALBUQUERQUE NM
87121-9021
US

IV. Provider business mailing address

120 98TH ST NW STE C3
ALBUQUERQUE NM
87121-9021
US

V. Phone/Fax

Practice location:
  • Phone: 830-347-1844
  • Fax:
Mailing address:
  • Phone: 830-347-1844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: AISHA WILLIAMS
Title or Position: COO
Credential:
Phone: 830-347-1844