Provider Demographics
NPI:1215332754
Name:LEGACY DENTAL LLC
Entity type:Organization
Organization Name:LEGACY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:505-299-4431
Mailing Address - Street 1:4520 LOWER TERRACE CIR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2503
Mailing Address - Country:US
Mailing Address - Phone:505-299-4431
Mailing Address - Fax:505-291-0265
Practice Address - Street 1:4520 LOWER TERRACE CIR NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2503
Practice Address - Country:US
Practice Address - Phone:505-299-4431
Practice Address - Fax:505-291-0265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD3103261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental