Healthcare Provider Details

I. General information

NPI: 1831938174
Provider Name (Legal Business Name): PEGAH KHAMOOSHI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2024
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY OF NEW MEXICO, MSC06
ALBUQUERQUE NM
87131
US

IV. Provider business mailing address

1 UNIVERSITY OF NEW MEXICO, MSC06 3500
ALBUQUERQUE NM
87131
US

V. Phone/Fax

Practice location:
  • Phone: 505-925-4031
  • Fax: 505-925-4030
Mailing address:
  • Phone: 505-925-4031
  • Fax: 505-925-4030

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 StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDB-2024-0227
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberDB-2024-0227
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: