Provider Demographics
NPI:1497960561
Name:AN, BONGMIN (DDS)
Entity Type:Individual
Prefix:
First Name:BONGMIN
Middle Name:
Last Name:AN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1748 S TRIVIZ DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-5103
Mailing Address - Country:US
Mailing Address - Phone:575-522-1983
Mailing Address - Fax:575-522-3435
Practice Address - Street 1:1748 S TRIVIZ DR
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-5103
Practice Address - Country:US
Practice Address - Phone:575-522-1983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD5580122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist