Provider Demographics
NPI:1639397854
Name:ORTHODONTIC SPECIALISTS OF ALBUQUERQUE SANTA FE
Entity Type:Organization
Organization Name:ORTHODONTIC SPECIALISTS OF ALBUQUERQUE SANTA FE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:B
Authorized Official - Last Name:SILVERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:505-822-1234
Mailing Address - Street 1:8216 LOUISIANA BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-2105
Mailing Address - Country:US
Mailing Address - Phone:505-822-1234
Mailing Address - Fax:
Practice Address - Street 1:8216 LOUISIANA BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2105
Practice Address - Country:US
Practice Address - Phone:505-822-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2277174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM179859Medicaid
NM13602Medicaid