San Juan Oral & Facial Surgery

Key facts

NPI: 1104228329
Entity type: Organization (NPI type 2)
Primary specialty: Oral and Maxillofacial Surgery (Dentist) 1223S0112X
Legal business name: SAN JUAN ORAL & FACIAL SURGERY
Practice address: 2990 E Pinon Frontage Rd Ste 102
Farmington, NM 87402-5068
Phone: (505) 333-8635
Fax: (505) 258-4909
NPI assigned: Sep 18, 2014
Organization subpart: No

Authorized official

Name: Beverly K Bradford, DDS
Title: Office Manager
Phone: (505) 333-8635

National Provider Directory

Locations

2990 E Pinon Frontage Rd
Ste 102
Farmington, NM 87402
Phone (505) 333-8635

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
Oral and Maxillofacial Surgery (Dentist) Group: 193400000X SINGLE SPECIALTY GROUP	1223S0112X			Yes

Addresses

Primary practice location

2990 E Pinon Frontage Rd Ste 102
Farmington, NM 87402-5068

Mailing address

2990 E Pinon Frontage Rd Ste 102
Farmington, NM 87402-5068
Phone (505) 333-8635

Other identifiers

Identifier	Type	State	Issuer
27077748	Medicaid	NM

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Mar 3, 2021.

{
    "created_epoch": "1410998400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1614729600000",
    "number": "1104228329",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2990 E PINON FRONTAGE RD STE 102",
            "city": "FARMINGTON",
            "state": "NM",
            "postal_code": "874025068",
            "telephone_number": "505-333-8635",
            "fax_number": "505-258-4909"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2990 E PINON FRONTAGE RD STE 102",
            "city": "FARMINGTON",
            "state": "NM",
            "postal_code": "874025068",
            "telephone_number": "505-333-8635",
            "fax_number": "505-258-4909"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SAN JUAN ORAL & FACIAL SURGERY",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-09-18",
        "last_updated": "2021-03-03",
        "certification_date": "2021-03-03",
        "status": "A",
        "authorized_official_last_name": "BRADFORD",
        "authorized_official_first_name": "BEVERLY",
        "authorized_official_middle_name": "K",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "505-333-8635",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "27077748",
            "state": "NM"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Farmington, NM

All providers in Farmington, NM · Oral and Maxillofacial Surgery (Dentist) in New Mexico

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 3, 2021. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.