Provider Demographics
NPI:1174772016
Name:DOCKSTADER, JEREMY R (DMD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:R
Last Name:DOCKSTADER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 LOMAS BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110
Mailing Address - Country:US
Mailing Address - Phone:505-232-2273
Mailing Address - Fax:
Practice Address - Street 1:4701 LOMAS BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-6233
Practice Address - Country:US
Practice Address - Phone:505-232-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-16
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD3444122300000X
UT7106444-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM273267056Medicaid