Provider Demographics
NPI:1033899547
Name:SOUTHWEST DENTAL SERVICES LLC
Entity Type:Organization
Organization Name:SOUTHWEST DENTAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:505-249-4683
Mailing Address - Street 1:3924 BAY HILL LOOP SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-8251
Mailing Address - Country:US
Mailing Address - Phone:505-249-4683
Mailing Address - Fax:
Practice Address - Street 1:4701 LOMAS BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-6233
Practice Address - Country:US
Practice Address - Phone:505-232-2273
Practice Address - Fax:505-255-2990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty