Healthcare Provider Details

I. General information

NPI: 1487023636
Provider Name (Legal Business Name): NMBFD LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2015
Last Update Date: 09/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 BOSQUE FARMS BLVD
BOSQUE FARMS NM
87068-9326
US

IV. Provider business mailing address

4146 NEUMAN RD
SAINT CLAIR MI
48079-3234
US

V. Phone/Fax

Practice location:
  • Phone: 505-869-2371
  • Fax:
Mailing address:
  • Phone: 810-941-8983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DANA SEXTON
Title or Position: GENERAL MANAGER
Credential:
Phone: 810-941-8983