Healthcare Provider Details

I. General information

NPI: 1790097160
Provider Name (Legal Business Name): JOHN B GILBRETH D.D.S M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2010
Last Update Date: 01/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

4111 BARBARA LOOP SE SUITE 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 TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDD3973
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: