Healthcare Provider Details

I. General information

NPI: 1891372389
Provider Name (Legal Business Name): CRANIOFACIAL SLEEP MEDICINE AND TMJ OF NEW MEXICO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2021
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8311 SAN PEDRO DR NE STE 3
ALBUQUERQUE NM
87113-2540
US

IV. Provider business mailing address

8311 SAN PEDRO DR NE STE 3
ALBUQUERQUE NM
87113-2540
US

V. Phone/Fax

Practice location:
  • Phone: 505-433-2107
  • Fax: 505-508-2674
Mailing address:
  • Phone: 505-433-2107
  • Fax: 505-508-2674

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: DR. ERIC J COONTZ
Title or Position: OWNER/OPERATOR
Credential: DDS,MS
Phone: 505-433-2107