Healthcare Provider Details

I. General information

NPI: 1265835177
Provider Name (Legal Business Name): GILBRETH GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2014
Last Update Date: 10/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4111 BARBARA LOOP SE STE B
RIO RANCHO NM
87124-1068
US

IV. Provider business mailing address

4111 BARBARA LOOP SE STE B
RIO RANCHO NM
87124-1068
US

V. Phone/Fax

Practice location:
  • Phone: 505-903-6916
  • Fax: 505-903-7188
Mailing address:
  • Phone: 505-903-6916
  • Fax: 505-903-7188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDD3973
License Number StateNM

VIII. Authorized Official

Name: DR. JOHN BRIAN GILBRETH
Title or Position: MANAGER
Credential: D.D.S M.S.
Phone: 505-903-6916