1601 2nd Street Gallup Professional, LLC
Dentist, General Practice in Gallup, NM. Organization (NPI-2).
NPI number1386309870
StatusActive
Last updated in NPPESNov 1, 2021
Details
- NPI
- 1386309870
- Entity type
- Organization (NPI-2)
- Legal business name
- 1601 2nd Street Gallup Professional, LLC
- Organization subpart
- No
- Enumeration date
- Nov 1, 2021
- Certification date
- Oct 12, 2021
- Last updated
- Nov 1, 2021
Taxonomy and licenses
| Taxonomy code | Description | License | State | Primary |
|---|---|---|---|---|
| 1223G0001X | Dentist, General Practice | – | – | Yes |
Other names
- Sundance Dental Care Of Gallup (Doing Business As)
Practice location
1601 S Second StGallup, NM 87301-5816
Phone 505-722-4422 · Fax 505-722-2060
Mailing address
1601 S Second StGallup, NM 87301-5816
Phone 505-722-4422 · Fax 505-722-2060
Authorized official
Peter Grmbos
Owner/Dentist
5057224422
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