Provider Demographics
NPI:1295277903
Name:LEGACY DENTAL PARTNERS LLC
Entity type:Organization
Organization Name:LEGACY DENTAL PARTNERS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:505-314-6526
Mailing Address - Street 1:5343 WYOMING BLVD NE
Mailing Address - Street 2:STE A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3199
Mailing Address - Country:US
Mailing Address - Phone:505-822-8777
Mailing Address - Fax:
Practice Address - Street 1:5343 WYOMING BLVD NE
Practice Address - Street 2:STE A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3199
Practice Address - Country:US
Practice Address - Phone:505-822-8777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-11
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD3103122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM01076370Medicaid