Healthcare Provider Details

I. General information

NPI: 1609888502
Provider Name (Legal Business Name): BENJAMIN DAVID TEITELBAUM DOM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 STATE ROAD 150 SUITE 2, VENADO PLAZA
EL PRADO NM
87529
US

IV. Provider business mailing address

PO BOX 2068
EL PRADO NM
87529-2068
US

V. Phone/Fax

Practice location:
  • Phone: 505-776-1067
  • Fax:
Mailing address:
  • Phone: 505-776-1067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number369
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: