Provider Demographics
NPI:1457527368
Name:SOUTHWEST ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:SOUTHWEST ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:MD,DDS
Authorized Official - Phone:505-797-3530
Mailing Address - Street 1:5900 CUBERO DR NE STE A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3879
Mailing Address - Country:US
Mailing Address - Phone:505-797-3530
Mailing Address - Fax:505-797-2155
Practice Address - Street 1:5900 CUBERO DR NE STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3879
Practice Address - Country:US
Practice Address - Phone:505-797-3530
Practice Address - Fax:505-797-2155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD10941223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME1446Medicaid