Provider Demographics
NPI:1356705305
Name:DR. DENTAL OF NEW MEXICO
Entity type:Organization
Organization Name:DR. DENTAL OF NEW MEXICO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNEEL
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:NAMBURI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:630-730-9676
Mailing Address - Street 1:800 JUAN TABO BLVD NE STE Q
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87123-1444
Mailing Address - Country:US
Mailing Address - Phone:505-554-2262
Mailing Address - Fax:505-554-2697
Practice Address - Street 1:800 JUAN TABO BLVD NE STE Q
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87123-1444
Practice Address - Country:US
Practice Address - Phone:505-554-2262
Practice Address - Fax:505-554-2697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-06
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD4343122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM32284756Medicaid