Provider Demographics
NPI:1952505208
Name:GALLUP INDIAN MEDICAL CENTER
Entity Type:Organization
Organization Name:GALLUP INDIAN MEDICAL CENTER
Other - Org Name:FORT WINGATE DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ACTING CEO
Authorized Official - Prefix:
Authorized Official - First Name:BENNIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:YAZZIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-722-1000
Mailing Address - Street 1:516 E. NIZHONI BLVD
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-1337
Mailing Address - Country:US
Mailing Address - Phone:505-722-1770
Mailing Address - Fax:505-722-1796
Practice Address - Street 1:520 B SHUSH DRIVE
Practice Address - Street 2:EXIT 33 STATE ROAD 400
Practice Address - City:FT . WINGATE
Practice Address - State:NM
Practice Address - Zip Code:87316
Practice Address - Country:US
Practice Address - Phone:505-722-1770
Practice Address - Fax:505-722-1796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
9435261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM27603725Medicaid