Healthcare Provider Details

I. General information

NPI: 1437165255
Provider Name (Legal Business Name): LIDIO GREGORIO RAINALDI JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 NIZHONI BLVD STE A
GALLUP NM
87301
US

IV. Provider business mailing address

501 NIZHONI BLVD STE A
GALLUP NM
87301
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-9363
  • Fax: 505-863-2554
Mailing address:
  • Phone: 505-863-9363
  • Fax: 505-863-2554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberNM1449
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: