Provider Demographics
NPI:1629356209
Name:OMNI DENTAL, LLC
Entity Type:Organization
Organization Name:OMNI DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-888-5131
Mailing Address - Street 1:7111 PROSPECT PL NE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-4309
Mailing Address - Country:US
Mailing Address - Phone:505-888-5131
Mailing Address - Fax:505-888-5135
Practice Address - Street 1:7111 PROSPECT PL NE
Practice Address - Street 2:SUITE B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4309
Practice Address - Country:US
Practice Address - Phone:505-888-5131
Practice Address - Fax:505-888-5135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2344122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1505220OtherUNITED CONCORDIA
NM55120725Medicaid