Healthcare Provider Details

I. General information

NPI: 1235300237
Provider Name (Legal Business Name): RIO GRANDE ORAL AND MAXILLOFACIAL SURGERY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2008
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8228 LOUISIANA BLVD NE STE B
ALBUQUERQUE NM
87113-2427
US

IV. Provider business mailing address

8228 LOUISIANA BLVD NE STE B
ALBUQUERQUE NM
87113-2427
US

V. Phone/Fax

Practice location:
  • Phone: 505-821-2111
  • Fax:
Mailing address:
  • Phone: 505-821-2111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number2698
License Number StateNM

VIII. Authorized Official

Name: GREGORY R MCGEE
Title or Position: PRESIDENT
Credential: DMD
Phone: 505-821-2111