WESTSIDE PEDIATRIC DENTISTRY NPI 1790808111

NPI Information

  • NPI: 1790808111
  • Provider Name: WESTSIDE PEDIATRIC DENTISTRY
  • Classification: Dentist - 1223P0221X
  • Specialization: Pediatric Dentistry
  • Entity Type: Organization
  • Address: 1724 GRANDE BLVD SE
    RIO RANCHO, NM
    ZIP 87124
  • Phone: (505) 896-0245

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NPI Details

WESTSIDE PEDIATRIC DENTISTRY is a pediatric dentistry dentist in Rio Rancho, NM. The provider is an age-defined specialty that provides both primary and comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs. WESTSIDE PEDIATRIC DENTISTRY NPI is 1790808111. The provider is registered as an organization entity type and is a single specialty group.

The provider's business location address is:

1724 GRANDE BLVD SE
RIO RANCHO, NM
ZIP 87124-726
Phone: (505) 896-0245
Fax: (505) 892-7579

The provider's authorized official is Raymond Eddie Broussard .
The authorized official title is Owner and has the following contact phone number (505) 896-0245.

The enumeration date for this NPI number is 4/9/2007 and was last updated on 8/22/2020.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
11223P0221XDentistPediatric DentistryDD1745NEW MEXICOYes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
183918MEDICAIDNEW MEXICO

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 11/21/2025

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