Organization
GREAT WHITE DENTISTRY
Active
Other names
Isham Dental
Organization subpart
No
Provider details
NPI number
Authorized official
DR. MICHAEL SCOTT ISHAM DMD (OWNER/DENTIST)
(505) 881-0422
Entity
Organization
Contact information
Practice address
5555 MONTGOMERY BLVD NE STE 17, ALBUQUERQUE, NM 87109-1445
(505) 881-0422
Mailing address
5555 MONTGOMERY BLVD NE STE 17, ALBUQUERQUE, NM 87109-1445
(505) 881-0422
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
DD4733
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
48108588
—
NM
Enumeration date
06/21/2018
Last updated
06/21/2018
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