Provider Demographics
NPI:1861563082
Name:MODERN DENTAL PROFESSIONALS NEW MEXICO PC
Entity type:Organization
Organization Name:MODERN DENTAL PROFESSIONALS NEW MEXICO PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:TOLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-332-3544
Mailing Address - Street 1:201 SANDPOINTE AVE
Mailing Address - Street 2:8TH FLOOR
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92707-5778
Mailing Address - Country:US
Mailing Address - Phone:505-332-3544
Mailing Address - Fax:505-332-4047
Practice Address - Street 1:8401 OSUNA RD NE
Practice Address - Street 2:SUITE B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2074
Practice Address - Country:US
Practice Address - Phone:505-332-3544
Practice Address - Fax:505-332-4047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD24851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty