Provider Demographics
NPI:1427379130
Name:SJOSTROM, DANEN (DDS, PHD)
Entity Type:Individual
Prefix:DR
First Name:DANEN
Middle Name:
Last Name:SJOSTROM
Suffix:
Gender:M
Credentials:DDS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7007 WYOMING BLVD NE
Mailing Address - Street 2:SUITE C-2
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3987
Mailing Address - Country:US
Mailing Address - Phone:614-949-9685
Mailing Address - Fax:
Practice Address - Street 1:7007 WYOMING BLVD NE
Practice Address - Street 2:SUITE C-2
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3987
Practice Address - Country:US
Practice Address - Phone:614-949-9685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-16
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD36471223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry