1730137217 NPI number — ALBUQUERQUE WEST SMILES YOUTH DENTISTRY, PC

Table of content: (NPI 1730137217)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730137217 NPI number — ALBUQUERQUE WEST SMILES YOUTH DENTISTRY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALBUQUERQUE WEST SMILES YOUTH DENTISTRY, PC
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:
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:
1730137217
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 COORS BLVD NW STE E6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87121-2009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-352-3808
Provider Business Mailing Address Fax Number:
505-352-3811

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 COORS BLVD NW
Provider Second Line Business Practice Location Address:
E-6
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87121-2006
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-352-3808
Provider Business Practice Location Address Fax Number:
505-352-3811
Provider Enumeration Date:
05/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FREEMAN
Authorized Official First Name:
KIM
Authorized Official Middle Name:
Authorized Official Title or Position:
REGIONAL MANAGER
Authorized Official Telephone Number:
505-377-9911

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 77532 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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