1356027858 NPI number — SIGNATURE NEW MEXICO DENTAL PARTNERS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356027858 NPI number — SIGNATURE NEW MEXICO DENTAL PARTNERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SIGNATURE NEW MEXICO DENTAL PARTNERS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356027858
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
410 N 44TH ST STE 290
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85008-7622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-234-8490
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3900 EUBANK BLVD NE STE 14
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87111-3427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-293-8011
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/27/2023

Additional Information

Authorized Official

Authorized Official Last Name:
BENNION
Authorized Official First Name:
MELODY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF INTEGRATIONS
Authorized Official Telephone Number:
480-234-8490

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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