Provider Demographics
NPI:1245533439
Name:RIO RANCHO ORAL AND MAXILLOFACIAL SURGERY PC
Entity type:Organization
Organization Name:RIO RANCHO ORAL AND MAXILLOFACIAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROGEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:505-994-4772
Mailing Address - Street 1:P.O. BOX 45895
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87174-5895
Mailing Address - Country:US
Mailing Address - Phone:505-994-4772
Mailing Address - Fax:505-994-1925
Practice Address - Street 1:1316 JACKIE ROAD SE
Practice Address - Street 2:SUITE 600
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-6606
Practice Address - Country:US
Practice Address - Phone:505-994-4772
Practice Address - Fax:505-994-1925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-10
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1538261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00085266Medicaid
NM2202943Medicare PIN
NMT40824Medicare UPIN