Healthcare Provider Details

I. General information

NPI: 1871961045
Provider Name (Legal Business Name): GREGORY R MCALLISTER, DDS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2015
Last Update Date: 09/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5910 CUBERO DR NE STE B
ALBUQUERQUE NM
87109-3868
US

IV. Provider business mailing address

5910 CUBERO DR NE STE B
ALBUQUERQUE NM
87109-3868
US

V. Phone/Fax

Practice location:
  • Phone: 505-243-7655
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number1837
License Number StateNM

VIII. Authorized Official

Name: SONJIA MACE
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-243-7655