Provider Demographics
NPI:1528593001
Name:AAA DENTAL
Entity Type:Organization
Organization Name:AAA DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-554-2262
Mailing Address - Street 1:800 JUAN TABO BLVD NE
Mailing Address - Street 2:STE-Q
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-1444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:505-554-2697
Practice Address - Street 1:3803 ATRISCO DR NW
Practice Address - Street 2:STE-D
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-4956
Practice Address - Country:US
Practice Address - Phone:505-833-1550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD35951223G0001X
NMDD43431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM32284756Medicaid
NM54001871Medicaid