Provider Demographics
NPI:1407190119
Name:ANTONIO, JOHN E JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:ANTONIO
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2108 REX CT NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-3661
Mailing Address - Country:US
Mailing Address - Phone:505-440-4498
Mailing Address - Fax:
Practice Address - Street 1:6349 U.S. HIGHWAY 550
Practice Address - Street 2:
Practice Address - City:CUB
Practice Address - State:NM
Practice Address - Zip Code:87013
Practice Address - Country:US
Practice Address - Phone:575-289-3291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-19
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD3776122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist