Healthcare Provider Details

I. General information

NPI: 1497849186
Provider Name (Legal Business Name): ALBUQUERQUE I.H.S. DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9169 COORS ROAD, NW
ALBUQUERQUE NM
87120
US

IV. Provider business mailing address

P.O. BOX 67830
ALBUQUERQUE NM
87193
US

V. Phone/Fax

Practice location:
  • Phone: 505-346-2306
  • Fax:
Mailing address:
  • Phone: 505-346-2306
  • 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: MS. MAUREEN R. CORDOVA
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 505-922-4248