Provider Demographics
NPI:1871922807
Name:BEAR CANYON ORAL & FACIAL SURGERY
Entity type:Organization
Organization Name:BEAR CANYON ORAL & FACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:RUDD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-292-3400
Mailing Address - Street 1:10151 MONTGOMERY NE STE 2-D
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111
Mailing Address - Country:US
Mailing Address - Phone:505-292-3400
Mailing Address - Fax:505-292-7124
Practice Address - Street 1:10151 MONTGOMERY NE STE 2-D
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111
Practice Address - Country:US
Practice Address - Phone:505-292-3400
Practice Address - Fax:505-292-7124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD3881261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical