Organization
WESTSIDE PEDIATRIC DENTISTRY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. RAYMOND EDDIE BROUSSARD DDS (OWNER)
(505) 896-0245
Entity
Organization
Contact information
Practice address
1724 GRANDE BLVD SE, RIO RANCHO, NM 87124-1726
(505) 896-0245
(505) 892-7579
Mailing address
1724 GRANDE BLVD SE, RIO RANCHO, NM 87124-1726
(505) 896-0245
(505) 892-7579
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
DD1745
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
83918
—
NM
Enumeration date
04/09/2007
Last updated
08/22/2020
Update your record
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