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General NPI Number Information
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NPI Number | 1023344579
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Entity Type | Organization
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Legal Business Name | RIO RANCHO DENTAL CENTER
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Dates
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Enumeration Date | 10/19/2009
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Last Update Date | 02/17/2014
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Provider Practice Location Address
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Address Line | 1316 JACKIE RD SE STE 300
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City | RIO RANCHO
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State | NM
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Zip | 87124-1045
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Country | US
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Telephone | 505-994-9693
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Fax |
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Provider Business Mailing Address
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Address Line | 1316 JACKIE RD SE STE 300
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City | RIO RANCHO
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State | NM
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Zip | 87124-1045
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Country | US
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Telephone | 505-994-9693
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. MARY A WHITLOW
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Credential |
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Telephone | 505-994-9693
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DD1498
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License Number State | NM
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