Healthcare Provider Details

I. General information

NPI: 1245533439
Provider Name (Legal Business Name): RIO RANCHO ORAL AND MAXILLOFACIAL SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2010
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 JACKIE ROAD SE SUITE 600
RIO RANCHO NM
87124-6606
US

IV. Provider business mailing address

P.O. BOX 45895
RIO RANCHO NM
87174-5895
US

V. Phone/Fax

Practice location:
  • Phone: 505-994-4772
  • Fax: 505-994-1925
Mailing address:
  • Phone: 505-994-4772
  • Fax: 505-994-1925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberDD1538
License Number StateNM

VIII. Authorized Official

Name: DR. LAURENCE J ROGEL
Title or Position: PRESIDENT
Credential: DDS
Phone: 505-994-4772