Healthcare Provider Details

I. General information

NPI: 1215544432
Provider Name (Legal Business Name): CORONADO FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 11/13/2020
Certification Date: 11/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11130 LOMAS BLVD NE STE F2
ALBUQUERQUE NM
87112-5581
US

IV. Provider business mailing address

11130 LOMAS BLVD NE STE F2
ALBUQUERQUE NM
87112-5581
US

V. Phone/Fax

Practice location:
  • Phone: 505-369-6451
  • Fax:
Mailing address:
  • Phone: 505-369-6451
  • 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: BECKY CHIEM
Title or Position: DR
Credential: DDS
Phone: 505-369-6451