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General NPI Number Information
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NPI Number | 1104228329
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Entity Type | Organization
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Legal Business Name | SAN JUAN ORAL & FACIAL SURGERY
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Dates
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Enumeration Date | 09/18/2014
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Last Update Date | 03/03/2021
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Provider Practice Location Address
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Address Line | 2990 E PINON FRONTAGE RD STE 102
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City | FARMINGTON
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State | NM
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Zip | 87402-5068
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Country | US
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Telephone | 505-333-8635
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Fax | 505-258-4909
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Provider Business Mailing Address
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Address Line | 2990 E PINON FRONTAGE RD STE 102
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City | FARMINGTON
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State | NM
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Zip | 87402-5068
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Country | US
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Telephone | 505-333-8635
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Fax | 505-258-4909
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | BEVERLY K BRADFORD
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Credential | DDS
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Telephone | 505-333-8635
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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