Provider Demographics
NPI:1982692091
Name:CANDELARIA, JOHN J (DDS)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:CANDELARIA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6628 DEERBOURNE RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4726
Mailing Address - Country:US
Mailing Address - Phone:505-899-9772
Mailing Address - Fax:
Practice Address - Street 1:120 S 9TH ST
Practice Address - Street 2:
Practice Address - City:BELEN
Practice Address - State:NM
Practice Address - Zip Code:87002-3102
Practice Address - Country:US
Practice Address - Phone:505-861-1013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD22981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM26985579Medicaid