Healthcare Provider Details

I. General information

NPI: 1851248173
Provider Name (Legal Business Name): RIO GRANDE SMILES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2026
Last Update Date: 03/16/2026
Certification Date: 03/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 COORS BLVD NW STE F
ALBUQUERQUE NM
87120-1176
US

IV. Provider business mailing address

3200 COORS BLVD NW STE F
ALBUQUERQUE NM
87120-1176
US

V. Phone/Fax

Practice location:
  • Phone: 505-877-1113
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: LUIS EMERSON VICUNA
Title or Position: OWNER
Credential: DDS
Phone: 505-877-1113