Healthcare Provider Details

I. General information

NPI: 1750622072
Provider Name (Legal Business Name): ORTHODENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2013
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1748 W MALONEY AVE
GALLUP NM
87301-3333
US

IV. Provider business mailing address

1748 W MALONEY AVE
GALLUP NM
87301-3333
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-8100
  • Fax: 505-863-8064
Mailing address:
  • Phone: 505-863-8100
  • Fax: 505-863-8064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD3399
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD3399
License Number StateNM

VIII. Authorized Official

Name: JOSEPH A WILSON
Title or Position: OWNER
Credential: DMD, MSD
Phone: 505-325-8858