Provider Demographics
NPI:1730137217
Name:ALBUQUERQUE WEST SMILES YOUTH DENTISTRY, PC
Entity Type:Organization
Organization Name:ALBUQUERQUE WEST SMILES YOUTH DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-377-9911
Mailing Address - Street 1:111 COORS BLVD NW STE E6
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87121-2009
Mailing Address - Country:US
Mailing Address - Phone:505-352-3808
Mailing Address - Fax:505-352-3811
Practice Address - Street 1:111 COORS BLVD NW
Practice Address - Street 2:E-6
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121-2006
Practice Address - Country:US
Practice Address - Phone:505-352-3808
Practice Address - Fax:505-352-3811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM77532Medicaid