Healthcare Provider Details

I. General information

NPI: 1437519758
Provider Name (Legal Business Name): JOHN RYAN JEPPSEN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/29/2016
Last Update Date: 09/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 SAN MATEO BLVD NE STE E1
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

4411 SAN MATEO BLVD NE STE E1
ALBUQUERQUE NM
87109-2000
US

V. Phone/Fax

Practice location:
  • Phone: 505-872-4867
  • Fax: 505-872-9380
Mailing address:
  • Phone: 505-872-4867
  • Fax: 972-590-8809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5809
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: