Healthcare Provider Details

I. General information

NPI: 1013151307
Provider Name (Legal Business Name): WESTSIDE ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2009
Last Update Date: 04/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 GRANDE BLVD SE SUITE A
RIO RANCHO NM
87124-1653
US

IV. Provider business mailing address

2320 GRANDE BLVD SE SUITE A
RIO RANCHO NM
87124-1653
US

V. Phone/Fax

Practice location:
  • Phone: 505-891-2100
  • Fax:
Mailing address:
  • Phone: 505-891-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDD2741
License Number StateNM

VIII. Authorized Official

Name: DR. JOHN HARMON
Title or Position: OWNER
Credential: DDS
Phone: 505-891-2100