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General NPI Number Information
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NPI Number | 1215332754
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Entity Type | Organization
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Legal Business Name | LEGACY DENTAL LLC
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Dates
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Enumeration Date | 10/27/2014
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Last Update Date | 10/27/2014
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Provider Practice Location Address
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Address Line | 4520 LOWER TERRACE CIR NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87111-2503
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Country | US
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Telephone | 505-299-4431
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Fax | 505-291-0265
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Provider Business Mailing Address
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Address Line | 4520 LOWER TERRACE CIR NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87111-2503
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Country | US
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Telephone | 505-299-4431
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Fax | 505-291-0265
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. STEWART J ANDERSON
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Credential | DMD
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Telephone | 505-299-4431
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DD3103
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License Number State | NM
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