Provider Demographics
NPI:1003355363
Name:CHODOSH, DAVID (DDS)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:CHODOSH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 MOUNTAIN RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2070
Mailing Address - Country:US
Mailing Address - Phone:203-536-0508
Mailing Address - Fax:
Practice Address - Street 1:2200 GRANDE BLVD SE STE A
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124
Practice Address - Country:US
Practice Address - Phone:505-891-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-20
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD46901223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty