MEDICARE: ALBUQUERQUE DENTIST OFFICE, 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	:	1558753236
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALBUQUERQUE DENTIST OFFICE, LLC

Provider Business Mailing Address
First Line	:	17000 RED HILL AVE
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92614-5626
Country	:	US
Telephone Number	:	714-845-8890
Fax Number	:	949-474-1495

Provider Business Practice Location Address
First Line	:	10221 CENTRAL AVE NE
Second Line	:	103
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87123-2733
Country	:	US
Telephone Number	:	505-918-9189
Fax Number	:	505-918-9175

Authorized Official
Title or Position	:	OWNER DOCTOR
Name	:	DR. KELLEY HOLLINGSWORTH RYALS
Credential	:	DDS
Telephone Number	:	505-918-9189

Provider Enumeration Date	:	03/04/2015
Last Update Date	:	03/04/2015

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