Provider Demographics
NPI:1326429622
Name:ABQ MODERN DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:ABQ MODERN DENTAL GROUP, LLC
Other - Org Name:ABQ MODERN DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLINGSWORTH RYALS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-323-1004
Mailing Address - Street 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:12611 MONTGOMERY BLVD NE
Practice Address - Street 2:A-1
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-4118
Practice Address - Country:US
Practice Address - Phone:505-323-1004
Practice Address - Fax:505-323-4355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty