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General NPI Number Information
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NPI Number | 1053901447
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Entity Type | Organization
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Legal Business Name | SANDIA PEAK DENTAL, LLC
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Dates
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Enumeration Date | 01/20/2021
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Last Update Date | 01/20/2021
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Provider Practice Location Address
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Address Line | 8000 EUBANK BLVD NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87122-3225
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Country | US
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Telephone | 505-298-6732
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Fax | 505-275-9976
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Provider Business Mailing Address
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Address Line | 8000 EUBANK BLVD NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87122-3225
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Country | US
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Telephone | 505-298-6732
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. JANSEN DONOGHUE
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Credential |
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Telephone | 505-298-6732
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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