Healthcare Provider Details

I. General information

NPI: 1477891083
Provider Name (Legal Business Name): GILBERTO ORNELAS JR. RDH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2013
Last Update Date: 01/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2118 CENTRAL AVE SE APT 167
ALBUQUERQUE NM
87106-4004
US

IV. Provider business mailing address

2118 CENTRAL AVE SE APT 167
ALBUQUERQUE NM
87106-4004
US

V. Phone/Fax

Practice location:
  • Phone: 505-453-5299
  • Fax:
Mailing address:
  • Phone: 505-453-5299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH3816
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: