Provider Demographics
NPI:1134427487
Name:ROSS FAMILY DENTAL
Entity type:Organization
Organization Name:ROSS FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-293-7441
Mailing Address - Street 1:10330 MONTGOMERY BLVD NE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3600
Mailing Address - Country:US
Mailing Address - Phone:505-293-7441
Mailing Address - Fax:
Practice Address - Street 1:10330 MONTGOMERY BLVD NE
Practice Address - Street 2:SUITE A
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3600
Practice Address - Country:US
Practice Address - Phone:505-293-7441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2625122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1104923085OtherINDIVIDUAL NPI
NM1124125091OtherINDIVIDUAL NPI