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General NPI Number Information
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NPI Number | 1255764650
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Entity Type | Organization
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Legal Business Name | NEW MEXICO PROFESSIONAL DENTAL ASSOCIATES, INC
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Dates
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Enumeration Date | 08/21/2013
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Last Update Date | 08/21/2013
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Provider Practice Location Address
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Address Line | 4120 BARBARA LOOP SE
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City | RIO RANCHO
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State | NM
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Zip | 87124-1000
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Country | US
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Telephone | 505-892-8088
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Fax |
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Provider Business Mailing Address
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Address Line | 4120 BARBARA LOOP SE
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City | RIO RANCHO
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State | NM
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Zip | 87124-1000
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Country | US
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Telephone | 505-892-8088
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING SUPERVISOR
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Name | KIM WILSON
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Credential |
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Telephone | 217-540-5170
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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