Provider Demographics
NPI:1043371842
Name:NORTHERN NEW MEXICO PERIODONTAL ASSOC.
Entity type:Organization
Organization Name:NORTHERN NEW MEXICO PERIODONTAL ASSOC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:PARKER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-988-8822
Mailing Address - Street 1:318 GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1933
Mailing Address - Country:US
Mailing Address - Phone:505-988-8822
Mailing Address - Fax:505-988-8824
Practice Address - Street 1:318 GRANT AVE
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1933
Practice Address - Country:US
Practice Address - Phone:505-988-8822
Practice Address - Fax:505-988-8824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD11251223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty