Healthcare Provider Details

I. General information

NPI: 1881011864
Provider Name (Legal Business Name): JEFFERY B WHEATON DDS MD AND ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2014
Last Update Date: 03/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490B W ZIA RD SUITE #3
SANTA FE NM
87505-7008
US

IV. Provider business mailing address

490B W. ZIA RD. SUITE #3
SANTA FE NM
87505
US

V. Phone/Fax

Practice location:
  • Phone: 505-992-1550
  • Fax:
Mailing address:
  • Phone: 505-992-1550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2052
License Number StateNM

VIII. Authorized Official

Name: DR. JEFFERY B WHEATON
Title or Position: OWNER
Credential: DDS,MD
Phone: 505-992-1550