Healthcare Provider Details

I. General information

NPI: 1972166262
Provider Name (Legal Business Name): GRANDE DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2019
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 GRANDE BLVD SE STE A
RIO RANCHO NM
87124-1695
US

IV. Provider business mailing address

2200 GRANDE BLVD SE STE A
RIO RANCHO NM
87124-1695
US

V. Phone/Fax

Practice location:
  • Phone: 505-891-1500
  • Fax:
Mailing address:
  • Phone: 972-869-3789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: FAITH GASKINS
Title or Position: DIRECTOR OF CREDENTIALING
Credential:
Phone: 972-869-3789