Provider Demographics
NPI:1366837643
Name:NEW MEXICO PROFESSIONAL DENTAL ASSOCIATES, INC
Entity Type:Organization
Organization Name:NEW MEXICO PROFESSIONAL DENTAL ASSOCIATES, INC
Other - Org Name:ALEGRE DENTAL @ PETROGLYPHS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CRED SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5170
Mailing Address - Street 1:2116 VISTA OESTE NW STE 202
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-4341
Mailing Address - Country:US
Mailing Address - Phone:505-836-1076
Mailing Address - Fax:505-836-9809
Practice Address - Street 1:2116 VISTA OESTE NW STE 202
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-4341
Practice Address - Country:US
Practice Address - Phone:505-836-1076
Practice Address - Fax:505-836-9809
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW MEXICO PROFESSIONAL DENTAL ASSOCIATES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-02
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty