Provider Demographics
NPI:1578684205
Name:RIO GRANDE DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:RIO GRANDE DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER & PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-758-0531
Mailing Address - Street 1:107 PLAZA GARCIA
Mailing Address - Street 2:#E-10
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6256
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 PLAZA GARCIA
Practice Address - Street 2:#E-10
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6256
Practice Address - Country:US
Practice Address - Phone:505-758-0531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM16701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty