Provider Demographics
NPI:1285179549
Name:FAMILY DENTAL HEALTH CARE
Entity Type:Organization
Organization Name:FAMILY DENTAL HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:XAYAVONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-881-8979
Mailing Address - Street 1:4550 EUBANK BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111
Mailing Address - Country:US
Mailing Address - Phone:505-881-8979
Mailing Address - Fax:505-881-8979
Practice Address - Street 1:4550 EUBANK BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111
Practice Address - Country:US
Practice Address - Phone:505-881-8979
Practice Address - Fax:505-881-8979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-22
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1870122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty