Provider Demographics
NPI:1558753236
Name:ALBUQUERQUE DENTIST OFFICE, LLC
Entity Type:Organization
Organization Name:ALBUQUERQUE DENTIST OFFICE, LLC
Other - Org Name:ALBUQUERQUE DENTIST OFFICE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLINGSWORTH RYALS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-918-9189
Mailing Address - Street 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:10221 CENTRAL AVE NE
Practice Address - Street 2:103
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87123-2733
Practice Address - Country:US
Practice Address - Phone:505-918-9189
Practice Address - Fax:505-918-9175
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-04
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty