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General NPI Number Information
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NPI Number | 1518810191
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Entity Type | Organization
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Legal Business Name | IMPERIUM DENTAL GROUP LLC
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Dates
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Enumeration Date | 02/16/2026
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Last Update Date | 02/16/2026
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Provider Practice Location Address
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Address Line | 10621 UNSER BLVD NW STE G
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City | ALBUQUERQUE
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State | NM
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Zip | 87114-6487
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Country | US
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Telephone | 505-588-7709
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Fax | 505-212-4119
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Provider Business Mailing Address
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Address Line | 10621 UNSER BLVD NW STE G
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City | ALBUQUERQUE
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State | NM
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Zip | 87114-6487
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Country | US
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Telephone | 505-588-7709
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Fax | 505-212-4119
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Authorized Official
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Title or Position | OWNER
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Name | BONGMIN AN
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Credential | DDS
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Telephone | 505-588-7709
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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