Provider Demographics
NPI:1235300237
Name:RIO GRANDE ORAL AND MAXILLOFACIAL SURGERY, P.C.
Entity Type:Organization
Organization Name:RIO GRANDE ORAL AND MAXILLOFACIAL SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCGEE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:505-821-2111
Mailing Address - Street 1:8228 LOUISIANA BLVD NE STE B
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-2427
Mailing Address - Country:US
Mailing Address - Phone:505-821-2111
Mailing Address - Fax:
Practice Address - Street 1:8228 LOUISIANA BLVD NE STE B
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-2427
Practice Address - Country:US
Practice Address - Phone:505-821-2111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2698261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM2698OtherDENTAL LICENSE