Provider Demographics
NPI:1689876963
Name:ORAL AND MAXILLOFACIAL SURGERY ASSOCIATE OF NEW MEXICO, P.A.
Entity Type:Organization
Organization Name:ORAL AND MAXILLOFACIAL SURGERY ASSOCIATE OF NEW MEXICO, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-881-1130
Mailing Address - Street 1:6800 MONTGOMERY BLVD NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-1405
Mailing Address - Country:US
Mailing Address - Phone:505-881-1130
Mailing Address - Fax:
Practice Address - Street 1:6800 MONTGOMERY BLVD NE
Practice Address - Street 2:SUITE A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1405
Practice Address - Country:US
Practice Address - Phone:505-881-1130
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2009-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM02-256180-00-31223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM89797Medicaid