MEDICARE: NORTHERN NEW MEXICO PERIODONTAL ASSOC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	DD1125	NM

General Provider Information

NPI Number	:	1043371842
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHERN NEW MEXICO PERIODONTAL ASSOC.

Provider Business Mailing Address
First Line	:	318 GRANT AVE
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87501-1933
Country	:	US
Telephone Number	:	505-988-8822
Fax Number	:	505-988-8824

Provider Business Practice Location Address
First Line	:	318 GRANT AVE
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87501-1933
Country	:	US
Telephone Number	:	505-988-8822
Fax Number	:	505-988-8824

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WILLIAM DEAN PARKER
Credential	:	D.D.S
Telephone Number	:	505-988-8822

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	08/22/2020

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Directions to “NORTHERN NEW MEXICO PERIODONTAL ASSOC. ” Practice Location

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