Provider Demographics
NPI:1770669368
Name:JORGENSEN, GREGORY J (DMD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:J
Last Name:JORGENSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 BARBARA LOOP SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1056
Mailing Address - Country:US
Mailing Address - Phone:505-891-9440
Mailing Address - Fax:
Practice Address - Street 1:1401 BARBARA LOOP SE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1056
Practice Address - Country:US
Practice Address - Phone:505-891-9440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD-17151223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics