Healthcare Provider Details

I. General information

NPI: 1023344579
Provider Name (Legal Business Name): RIO RANCHO DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2009
Last Update Date: 02/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 JACKIE RD SE STE 300
RIO RANCHO NM
87124-1045
US

IV. Provider business mailing address

1316 JACKIE RD SE STE 300
RIO RANCHO NM
87124-1045
US

V. Phone/Fax

Practice location:
  • Phone: 505-994-9693
  • Fax:
Mailing address:
  • Phone: 505-994-9693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD1498
License Number StateNM

VIII. Authorized Official

Name: MRS. MARY A WHITLOW
Title or Position: OFFICE MANAGER
Credential:
Phone: 505-994-9693