Healthcare Provider Details

I. General information

NPI: 1205526530
Provider Name (Legal Business Name): DENTAL DESIGN STUDIO LLC DBA IVORY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5920 WHITEMAN DR NW
ALBUQUERQUE NM
87120-2198
US

IV. Provider business mailing address

5920 WHITEMAN DR NW
ALBUQUERQUE NM
87120-2198
US

V. Phone/Fax

Practice location:
  • Phone: 505-897-6889
  • Fax: 505-922-1319
Mailing address:
  • Phone: 505-897-6889
  • Fax: 505-922-1319

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: MEAH WASHINGTON
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-897-6889