Provider Demographics
NPI:1891372389
Name:CRANIOFACIAL SLEEP MEDICINE AND TMJ OF NEW MEXICO, LLC
Entity type:Organization
Organization Name:CRANIOFACIAL SLEEP MEDICINE AND TMJ OF NEW MEXICO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:J
Authorized Official - Last Name:COONTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS
Authorized Official - Phone:505-433-2107
Mailing Address - Street 1:8311 SAN PEDRO DR NE STE 3
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-2540
Mailing Address - Country:US
Mailing Address - Phone:505-433-2107
Mailing Address - Fax:505-508-2674
Practice Address - Street 1:8311 SAN PEDRO DR NE STE 3
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2540
Practice Address - Country:US
Practice Address - Phone:505-433-2107
Practice Address - Fax:505-508-2674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-29
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental