Healthcare Provider Details

I. General information

NPI: 1811009855
Provider Name (Legal Business Name): PEARLY WHITES DENTAL OFFICE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4041 BARBARA LOOP SE SUITE A
RIO RANCHO NM
87124-1065
US

IV. Provider business mailing address

PO BOX 15256
RIO RANCHO NM
87174-0256
US

V. Phone/Fax

Practice location:
  • Phone: 505-891-1500
  • Fax: 505-891-8400
Mailing address:
  • Phone: 505-891-1500
  • Fax: 505-891-8400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD1948
License Number StateNM

VIII. Authorized Official

Name: SHIRLEY ANN PROFAZI
Title or Position: OWNER
Credential: RDH
Phone: 505-891-1500