Provider Demographics
NPI:1396865267
Name:NEW MEXICO CENTER FOR CRANIOFACIAL PAIN,LLC
Entity Type:Organization
Organization Name:NEW MEXICO CENTER FOR CRANIOFACIAL PAIN,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRABB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-883-6446
Mailing Address - Street 1:7111 PROSPECT PL NE
Mailing Address - Street 2:SUITE D-301
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-4309
Mailing Address - Country:US
Mailing Address - Phone:505-883-6446
Mailing Address - Fax:
Practice Address - Street 1:7111 PROSPECT PL NE
Practice Address - Street 2:SUITE D-301
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4309
Practice Address - Country:US
Practice Address - Phone:505-883-6446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMD664122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty