Provider Demographics
NPI:1710404504
Name:505 DENTAL LLC
Entity Type:Organization
Organization Name:505 DENTAL LLC
Other - Org Name:AMERICAN INSTITUTE OF DENTAL ASSISTING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JONAH
Authorized Official - Middle Name:L
Authorized Official - Last Name:FOUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-395-6240
Mailing Address - Street 1:2901 JUAN TABO BLVD NE STE 10
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-1885
Mailing Address - Country:US
Mailing Address - Phone:505-395-6240
Mailing Address - Fax:505-214-5132
Practice Address - Street 1:2901 JUAN TABO BLVD NE STE 10
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-1885
Practice Address - Country:US
Practice Address - Phone:505-395-6240
Practice Address - Fax:505-214-5132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDDS6621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty