Healthcare Provider Details

I. General information

NPI: 1487627618
Provider Name (Legal Business Name): RICHARD VERDERAME D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4111 BARBARA LOOP SE SUITE E-2
RIO RANCHO NM
87124-1068
US

IV. Provider business mailing address

4111 BARBARA LOOP SE SUITE E-2
RIO RANCHO NM
87124-1068
US

V. Phone/Fax

Practice location:
  • Phone: 505-891-3000
  • Fax: 505-891-3001
Mailing address:
  • Phone: 505-891-3000
  • Fax: 505-891-3001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDD1612
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: