Healthcare Provider Details

I. General information

NPI: 1134427487
Provider Name (Legal Business Name): ROSS FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2011
Last Update Date: 03/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10330 MONTGOMERY BLVD NE SUITE A
ALBUQUERQUE NM
87111-3600
US

IV. Provider business mailing address

10330 MONTGOMERY BLVD NE SUITE A
ALBUQUERQUE NM
87111-3600
US

V. Phone/Fax

Practice location:
  • Phone: 505-293-7441
  • Fax:
Mailing address:
  • Phone: 505-293-7441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2625
License Number StateNM

VIII. Authorized Official

Name: DR. KERRY ROSS
Title or Position: OWNER
Credential: DDS
Phone: 505-293-7441