Healthcare Provider Details

I. General information

NPI: 1518345552
Provider Name (Legal Business Name): SANDIA DENTAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 05/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 MONTGOMERY BLVD NE SUITE C
ALBUQUERQUE NM
87109-1405
US

IV. Provider business mailing address

6800 MONTGOMERY BLVD NE SUITE C
ALBUQUERQUE NM
87109-1405
US

V. Phone/Fax

Practice location:
  • Phone: 505-884-8000
  • Fax: 505-884-4012
Mailing address:
  • Phone: 505-884-8000
  • Fax: 505-884-4012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number2810
License Number StateNM

VIII. Authorized Official

Name: DR. SARAH L KASSAM
Title or Position: OWNER
Credential: DDS
Phone: 505-884-8000