Healthcare Provider Details

I. General information

NPI: 1902460033
Provider Name (Legal Business Name): GREG JORGENSEN, DMD, MS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 04/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 BARBARA LOOP SE
RIO RANCHO NM
87124-1056
US

IV. Provider business mailing address

1401 BARBARA LOOP SE
RIO RANCHO NM
87124-1056
US

V. Phone/Fax

Practice location:
  • Phone: 505-891-9440
  • Fax: 505-994-9743
Mailing address:
  • Phone: 505-891-9440
  • Fax: 505-994-9743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: LYNETTE BUTTS
Title or Position: FINANCIAL COORDINATOR
Credential:
Phone: 505-891-9440