Healthcare Provider Details

I. General information

NPI: 1003355363
Provider Name (Legal Business Name): DAVID CHODOSH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2017
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 GRANDE BLVD SE STE A
RIO RANCHO NM
87124
US

IV. Provider business mailing address

715 MOUNTAIN RD NW
ALBUQUERQUE NM
87102-2070
US

V. Phone/Fax

Practice location:
  • Phone: 505-891-1500
  • Fax:
Mailing address:
  • Phone: 203-536-0508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD4690
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD4690
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: