Facts
- Status
- A
- Credential
- D.D.S.
- Type
- Individual
- Enumeration date
- 2007-03-04
- Last updated
- 2007-07-08
Licenses
- License NM
- DD1562
- License AZ
- D3755
Location
- Practice location
- 1312 REDROCK DR
- City
- GALLUP NM
- Postal code
- 873015686
- Phone
- 505-722-5050
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.