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General NPI Number Information
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NPI Number | 1447500384
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Entity Type | Organization
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Legal Business Name | CDB RIO BRAVO LLC
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Dates
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Enumeration Date | 09/19/2012
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Last Update Date | 09/19/2012
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Provider Practice Location Address
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Address Line | 1625 RIO BRAVO BLVD SW
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City | ALBUQUERQUE
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State | NM
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Zip | 87105-6057
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Country | US
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Telephone | 505-850-0305
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Fax |
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Provider Business Mailing Address
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Address Line | 7120 CALLE ALEGRIA NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87113-1368
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DDS
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Name | DR. JONAH FOUTZ
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Credential |
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Telephone | 505-850-0305
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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 | DD3662
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License Number State | NM
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