Healthcare Provider Details

I. General information

NPI: 1104228329
Provider Name (Legal Business Name): SAN JUAN ORAL & FACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2990 E PINON FRONTAGE RD STE 102
FARMINGTON NM
87402-5068
US

IV. Provider business mailing address

2990 E PINON FRONTAGE RD STE 102
FARMINGTON NM
87402-5068
US

V. Phone/Fax

Practice location:
  • Phone: 505-333-8635
  • Fax: 505-258-4909
Mailing address:
  • Phone: 505-333-8635
  • Fax: 505-258-4909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: BEVERLY K BRADFORD
Title or Position: OFFICE MANAGER
Credential: DDS
Phone: 505-333-8635