Provider Demographics
NPI:1629615851
Name:SOUTHWEST ORAL AND MAXILLOFACIAL SURGEONS LLC
Entity Type:Organization
Organization Name:SOUTHWEST ORAL AND MAXILLOFACIAL SURGEONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WAI PONG
Authorized Official - Middle Name:
Authorized Official - Last Name:NG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:505-797-3530
Mailing Address - Street 1:5900 CUBERO DR NE STE A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3879
Mailing Address - Country:US
Mailing Address - Phone:505-797-3530
Mailing Address - Fax:505-797-2155
Practice Address - Street 1:5900 CUBERO DR NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3879
Practice Address - Country:US
Practice Address - Phone:505-797-3530
Practice Address - Fax:505-797-2155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical