Basic Information
| Provider Information | |||||||||
| NPI: | 1326429622 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ABQ MODERN DENTAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | ABQ MODERN DENTAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17000 RED HILL AVE | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926145626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148458890 | ||||||||
| FaxNumber: | 9494741495 | ||||||||
| Practice Location | |||||||||
| Address1: | 12611 MONTGOMERY BLVD NE | ||||||||
| Address2: | A-1 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871114118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5053231004 | ||||||||
| FaxNumber: | 5053234355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2015 | ||||||||
| LastUpdateDate: | 06/11/2015 | ||||||||
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| AuthorizedOfficialLastName: | HOLLINGSWORTH RYALS | ||||||||
| AuthorizedOfficialFirstName: | KELLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER DENTIST | ||||||||
| AuthorizedOfficialTelephone: | 5053231004 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.