MEDICARE: JUAN TABO DENTISTRY LLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1477197804
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUAN TABO DENTISTRY LLC

Provider Business Mailing Address
First Line	:	1924 JUAN TABO BLVD NE STE C
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-3358
Country	:	US
Telephone Number	:	505-293-3451
Fax Number	:

Provider Business Practice Location Address
First Line	:	1924 JUAN TABO BLVD NE STE C
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-3358
Country	:	US
Telephone Number	:	505-293-3451
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF CREDENTIALING
Name	:	FAITH GASKINS
Credential	:
Telephone Number	:	972-869-3789

Provider Enumeration Date	:	10/29/2019
Last Update Date	:	10/29/2019

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