Provider Demographics
NPI:1043487119
Name:COTTONWOOD MALL DENTAL PRACTICE, LLC
Entity Type:Organization
Organization Name:COTTONWOOD MALL DENTAL PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:SAPP
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-242-4867
Mailing Address - Street 1:10000 COORS BYP NW
Mailing Address - Street 2:# G-218
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4040
Mailing Address - Country:US
Mailing Address - Phone:505-242-4867
Mailing Address - Fax:505-890-2883
Practice Address - Street 1:10000 COORS BYP NW
Practice Address - Street 2:# G-218
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-4040
Practice Address - Country:US
Practice Address - Phone:505-242-4867
Practice Address - Fax:505-890-2883
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1440525OtherUNITED CONCORDIA