Provider Demographics
NPI:1447427513
Name:UPTOWN PARK DENTAL PRACTICE, LLC
Entity Type:Organization
Organization Name:UPTOWN PARK DENTAL PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAXEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-789-5224
Mailing Address - Street 1:2100 LOUISIANA BLVD NE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5419
Mailing Address - Country:US
Mailing Address - Phone:505-883-4867
Mailing Address - Fax:505-883-4007
Practice Address - Street 1:2100 LOUISIANA BLVD NE
Practice Address - Street 2:SUITE 104
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5419
Practice Address - Country:US
Practice Address - Phone:505-883-4867
Practice Address - Fax:505-883-4007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM0973127OtherUNITED CONCORIDA