=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306340823
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN AMOS KING RDH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2018
-----------------------------------------------------
Last Update Date | 03/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2017 SAN MATEO BLVD NE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87110-5147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-256-1081
-----------------------------------------------------
Fax | 505-255-3203
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1524 GERALD AVE SE
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87106-5025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-850-4266
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | DH3875
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------