Provider Demographics
NPI:1558709691
Name:C. MAHLON FRALEIGH, DDS, LLC
Entity Type:Organization
Organization Name:C. MAHLON FRALEIGH, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAUD
Authorized Official - Middle Name:MAHLON
Authorized Official - Last Name:FRALEIGH
Authorized Official - Suffix:II
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-293-2644
Mailing Address - Street 1:8400 OSUNA RD NE
Mailing Address - Street 2:STE 4-B
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2087
Mailing Address - Country:US
Mailing Address - Phone:505-293-2644
Mailing Address - Fax:505-293-2298
Practice Address - Street 1:8400 OSUNA RD NE
Practice Address - Street 2:STE 4-B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2087
Practice Address - Country:US
Practice Address - Phone:505-293-2644
Practice Address - Fax:505-293-2298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2619261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental