Healthcare Provider Details

I. General information

NPI: 1982033700
Provider Name (Legal Business Name): OUTREACH DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2013
Last Update Date: 11/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 HELENA DR
GALLUP NM
87301-5610
US

IV. Provider business mailing address

PO BOX 969
GALLUP NM
87305-0969
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-7887
  • Fax: 505-863-7887
Mailing address:
  • Phone: 505-863-7887
  • Fax: 505-863-7887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD1995
License Number StateNM

VIII. Authorized Official

Name: DR. STEPHEN SCOT GRAHAM
Title or Position: OWNER
Credential: D.D.S.
Phone: 505-863-7887