Provider Demographics
NPI:1992226401
Name:SUNSET DENTAL, LLC
Entity type:Organization
Organization Name:SUNSET DENTAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:TANG
Authorized Official - Last Name:NGO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-821-5437
Mailing Address - Street 1:6211 4TH ST NW STE 13
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-5762
Mailing Address - Country:US
Mailing Address - Phone:505-634-5541
Mailing Address - Fax:
Practice Address - Street 1:6211 4TH ST NW STE 13
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-5762
Practice Address - Country:US
Practice Address - Phone:505-821-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-05
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD4560261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM30570280Medicaid
NM20832800Medicaid