Provider Demographics
NPI:1356722078
Name:DENTAMAX DENTAL SERVICES LLC
Entity type:Organization
Organization Name:DENTAMAX DENTAL SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BOYD
Authorized Official - Middle Name:EMMITT
Authorized Official - Last Name:NEWSOME
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:480-250-8597
Mailing Address - Street 1:4421 IRVING BLVD NW
Mailing Address - Street 2:SUITE B
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-5919
Mailing Address - Country:US
Mailing Address - Phone:505-821-6910
Mailing Address - Fax:505-792-5771
Practice Address - Street 1:4421 IRVING BLVD NW
Practice Address - Street 2:SUITE B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-5919
Practice Address - Country:US
Practice Address - Phone:505-821-6910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD42831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty