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General NPI Number Information
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NPI Number | 1306650833
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Entity Type | Organization
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Legal Business Name | WISTERIA DENTAL LLC
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Dates
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Enumeration Date | 02/05/2025
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Last Update Date | 02/05/2025
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Provider Practice Location Address
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Address Line | 1904 WELLSPRING AVE SE
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City | RIO RANCHO
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State | NM
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Zip | 87124-4888
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Country | US
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Telephone | 505-896-6654
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Fax |
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Provider Business Mailing Address
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Address Line | 1904 WELLSPRING AVE SE
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City | RIO RANCHO
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State | NM
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Zip | 87124-4888
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Country | US
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Telephone | 505-896-6654
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Fax |
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Authorized Official
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Title or Position | OWNER DENTIST
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Name | TRANG LE
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Credential | DD
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Telephone | 505-896-6654
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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 |
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License Number State |
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