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General NPI Number Information
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NPI Number | 1629356209
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Entity Type | Organization
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Legal Business Name | OMNI DENTAL, LLC
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Dates
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Enumeration Date | 07/29/2011
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Last Update Date | 07/29/2011
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Provider Practice Location Address
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Address Line | 7111 PROSPECT PL NE SUITE B
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City | ALBUQUERQUE
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State | NM
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Zip | 87110-4309
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Country | US
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Telephone | 505-888-5131
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Fax | 505-888-5135
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Provider Business Mailing Address
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Address Line | 7111 PROSPECT PL NE SUITE B
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City | ALBUQUERQUE
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State | NM
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Zip | 87110-4309
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Country | US
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Telephone | 505-888-5131
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Fax | 505-888-5135
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Authorized Official
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Title or Position | CO-OWNER
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Name | DR. PE CHANG
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Credential | D.D.S.
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Telephone | 505-888-5131
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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 | DD2344
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License Number State | NM
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