Healthcare Provider Details

I. General information

NPI: 1578148474
Provider Name (Legal Business Name): DENTAL TRIBE NE ABQ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2021
Last Update Date: 03/11/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3520 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87107-4846
US

IV. Provider business mailing address

3520 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87107-4846
US

V. Phone/Fax

Practice location:
  • Phone: 505-888-2606
  • Fax:
Mailing address:
  • Phone: 505-888-2606
  • Fax: 505-837-1635

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: MRS. TAYLOR LOUISE RODAS
Title or Position: OFFICE MANAGER
Credential:
Phone: 760-987-0101