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General NPI Number Information
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NPI Number | 1316455017
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Entity Type | Organization
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Legal Business Name | PINO PERIODONTICS, LLC
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Dates
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Enumeration Date | 01/16/2018
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Last Update Date | 01/16/2018
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Provider Practice Location Address
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Address Line | 7007 WYOMING BLVD NE STE D1
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City | ALBUQUERQUE
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State | NM
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Zip | 87109-3981
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Country | US
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Telephone | 505-822-0565
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Fax | 505-821-4242
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Provider Business Mailing Address
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Address Line | PO BOX 94598
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City | ALBUQUERQUE
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State | NM
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Zip | 87199-4598
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Country | US
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Telephone | 505-822-0565
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Fax | 505-821-4242
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | REBECCA A PINO
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Credential |
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Telephone | 505-822-0565
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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