Westside Pediatric Dentistry

Primary specialty

Pediatric DentistryTaxonomy code 1223P0221X

License

DD1745 Issued in NM

Legal business name

WESTSIDE PEDIATRIC DENTISTRY

Practice address

1724 Grande Blvd SE
Rio Rancho, NM 87124-1726

Phone

(505) 896-0245

Fax

(505) 892-7579

NPI assigned

Apr 9, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Raymond Eddie Broussard, DDSNPI 1558478560

Title

Owner

Phone

(505) 896-0245

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Raymond Eddie Broussard, DDS

  • Dentist
  • Rio Rancho, NM
  • NPI 1558478560
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1176076800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1790808111",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1724 GRANDE BLVD SE",
            "city": "RIO RANCHO",
            "state": "NM",
            "postal_code": "871241726",
            "telephone_number": "505-896-0245",
            "fax_number": "505-892-7579"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1724 GRANDE BLVD SE",
            "city": "RIO RANCHO",
            "state": "NM",
            "postal_code": "871241726",
            "telephone_number": "505-896-0245",
            "fax_number": "505-892-7579"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WESTSIDE PEDIATRIC DENTISTRY",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-09",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "BROUSSARD",
        "authorized_official_first_name": "RAYMOND",
        "authorized_official_middle_name": "EDDIE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "505-896-0245",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223P0221X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "NM",
            "license": "DD1745",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "83918",
            "state": "NM"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Melissa Westfall
• Christiaan Westrom, LPCC
• Westside Endodontics
• Westside Family Medicine
• Westside Myofascial Center LLC
• Wfa LLC
• Barbara Lynn Wheeler, RN
• Elizabeth Wheeler, RN
• Vanessa Wheeler
• Whitney Whetten

• Pediatric Dentistry in Rio Rancho, NM
• Providers in Rio Rancho, NM by specialty
• Pediatric Dentistry in New Mexico

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.