Provider Demographics
NPI:1013390087
Name:CRDS
Entity Type:Organization
Organization Name:CRDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:CONNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:575-642-4779
Mailing Address - Street 1:2800 COORS BLVD NW STE A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1204
Mailing Address - Country:US
Mailing Address - Phone:505-350-1166
Mailing Address - Fax:505-352-2805
Practice Address - Street 1:2800 COORS BLVD NW STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-1204
Practice Address - Country:US
Practice Address - Phone:505-350-1166
Practice Address - Fax:505-352-2805
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALBUQUERQUE MODERN DENTISTRY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD4332122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty