Healthcare Provider Details

I. General information

NPI: 1932469376
Provider Name (Legal Business Name): WRN, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2012
Last Update Date: 10/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4701 LOMAS BLVD NE
ALBUQUERQUE NM
87110
US

IV. Provider business mailing address

4701 LOMAS BLVD NE
ALBUQUERQUE NM
87110-6233
US

V. Phone/Fax

Practice location:
  • Phone: 505-433-5204
  • Fax:
Mailing address:
  • Phone: 505-433-5204
  • 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: WILLIAM R NICHOLS
Title or Position: DIRECTOR
Credential:
Phone: 505-433-5204