Provider Demographics
NPI:1023344579
Name:RIO RANCHO DENTAL CENTER
Entity type:Organization
Organization Name:RIO RANCHO DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WHITLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-994-9693
Mailing Address - Street 1:1316 JACKIE RD SE STE 300
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1045
Mailing Address - Country:US
Mailing Address - Phone:505-994-9693
Mailing Address - Fax:
Practice Address - Street 1:1316 JACKIE RD SE STE 300
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1045
Practice Address - Country:US
Practice Address - Phone:505-994-9693
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-19
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD1498122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty