Healthcare Provider Details

I. General information

NPI: 1043371842
Provider Name (Legal Business Name): NORTHERN NEW MEXICO PERIODONTAL ASSOC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 GRANT AVE
SANTA FE NM
87501-1933
US

IV. Provider business mailing address

318 GRANT AVE
SANTA FE NM
87501-1933
US

V. Phone/Fax

Practice location:
  • Phone: 505-988-8822
  • Fax: 505-988-8824
Mailing address:
  • Phone: 505-988-8822
  • Fax: 505-988-8824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDD1125
License Number StateNM

VIII. Authorized Official

Name: DR. WILLIAM DEAN PARKER
Title or Position: PRESIDENT
Credential: D.D.S
Phone: 505-988-8822