Healthcare Provider Details

I. General information

NPI: 1306650833
Provider Name (Legal Business Name): WISTERIA DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2025
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 WELLSPRING AVE SE
RIO RANCHO NM
87124-4888
US

IV. Provider business mailing address

1904 WELLSPRING AVE SE
RIO RANCHO NM
87124-4888
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-6654
  • Fax:
Mailing address:
  • Phone: 505-896-6654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TRANG LE
Title or Position: OWNER DENTIST
Credential: DD
Phone: 505-896-6654