Provider Demographics
NPI:1144279381
Name:ALBUQUERQUE EAST SMILES YOUTH DENTISTRY, PC
Entity type:Organization
Organization Name:ALBUQUERQUE EAST SMILES YOUTH DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-377-9911
Mailing Address - Street 1:201 SAN PEDRO DR SE STE B2
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-3009
Mailing Address - Country:US
Mailing Address - Phone:505-232-5437
Mailing Address - Fax:505-254-7649
Practice Address - Street 1:201 SAN PEDRO DR SE
Practice Address - Street 2:SUITE B-2
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-3009
Practice Address - Country:US
Practice Address - Phone:505-232-5437
Practice Address - Fax:505-254-7649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-07
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM93175027Medicaid