=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235457607
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GALLUP DENTAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2010
-----------------------------------------------------
Last Update Date | 05/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1421 US 491
-----------------------------------------------------
City | GALLUP
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-863-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1312 REDROCK DR
-----------------------------------------------------
City | GALLUP
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87301-5686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-979-2023
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHAEL KORY ROWBERRY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 505-863-8000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DD1562
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------