Healthcare Provider Details

I. General information

NPI: 1215120910
Provider Name (Legal Business Name): JANUS J. DE CUNAE, DDS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2007
Last Update Date: 05/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2280 BOSQUE FARMS BLVD
BOSQUE FARMS NM
87068-9334
US

IV. Provider business mailing address

2280 BOSQUE FARMS BLVD
BOSQUE FARMS NM
87068-9334
US

V. Phone/Fax

Practice location:
  • Phone: 505-869-6500
  • Fax: 505-869-4036
Mailing address:
  • Phone: 505-869-6500
  • Fax: 505-869-4036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD2693
License Number StateNM

VIII. Authorized Official

Name: DR. JANUS JEAN DE CUNAE
Title or Position: PRESIDENT
Credential: DDS
Phone: 505-869-6500