Healthcare Provider Details

I. General information

NPI: 1790808111
Provider Name (Legal Business Name): WESTSIDE PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1724 GRANDE BLVD SE
RIO RANCHO NM
87124-1726
US

IV. Provider business mailing address

1724 GRANDE BLVD SE
RIO RANCHO NM
87124-1726
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-0245
  • Fax: 505-892-7579
Mailing address:
  • Phone: 505-896-0245
  • Fax: 505-892-7579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDD1745
License Number StateNM

VIII. Authorized Official

Name: DR. RAYMOND EDDIE BROUSSARD
Title or Position: OWNER
Credential: DDS
Phone: 505-896-0245