Provider Demographics
NPI:1639663792
Name:GREAT WHITE DENTISTRY
Entity Type:Organization
Organization Name:GREAT WHITE DENTISTRY
Other - Org Name:ISHAM DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:ISHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:505-881-0422
Mailing Address - Street 1:5555 MONTGOMERY BLVD NE STE 17
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1445
Mailing Address - Country:US
Mailing Address - Phone:505-881-0422
Mailing Address - Fax:
Practice Address - Street 1:5555 MONTGOMERY BLVD NE STE 17
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1445
Practice Address - Country:US
Practice Address - Phone:505-881-0422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-21
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD47331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM48108588Medicaid