Healthcare Provider Details

I. General information

NPI: 1174992564
Provider Name (Legal Business Name): CDB 550 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E HIGHWAY 550
BERNALILLO NM
87004-5967
US

IV. Provider business mailing address

120 E HIGHWAY 550
BERNALILLO NM
87004-5967
US

V. Phone/Fax

Practice location:
  • Phone: 505-550-0503
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD3662
License Number StateNM

VIII. Authorized Official

Name: DR. JONAH L FOUTZ
Title or Position: OWNER
Credential: DD3662
Phone: 505-550-0305