Provider Demographics
NPI:1306340823
Name:KING, JOHN AMOS (RDH)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:AMOS
Last Name:KING
Suffix:
Gender:M
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 GERALD AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-5025
Mailing Address - Country:US
Mailing Address - Phone:505-850-4266
Mailing Address - Fax:
Practice Address - Street 1:2017 SAN MATEO BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5147
Practice Address - Country:US
Practice Address - Phone:505-256-1081
Practice Address - Fax:505-255-3203
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH3875124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist