MEDICARE: IMPERIUM DENTAL GROUP 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	122300000X	Dentist

General Provider Information

NPI Number	:	1518810191
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMPERIUM DENTAL GROUP LLC

Provider Business Mailing Address
First Line	:	10621 UNSER BLVD NW STE G
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87114-6487
Country	:	US
Telephone Number	:	505-588-7709
Fax Number	:	505-212-4119

Provider Business Practice Location Address
First Line	:	10621 UNSER BLVD NW STE G
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87114-6487
Country	:	US
Telephone Number	:	505-588-7709
Fax Number	:	505-212-4119

Authorized Official
Title or Position	:	OWNER
Name	:	BONGMIN AN
Credential	:	DDS
Telephone Number	:	505-588-7709

Provider Enumeration Date	:	02/16/2026
Last Update Date	:	02/16/2026

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Directions to “IMPERIUM DENTAL GROUP LLC ” Practice Location

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