Provider Demographics
NPI:1871961045
Name:GREGORY R MCALLISTER, DDS, LLC
Entity type:Organization
Organization Name:GREGORY R MCALLISTER, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SONJIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-243-7655
Mailing Address - Street 1:5910 CUBERO DR NE STE B
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3868
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5910 CUBERO DR NE STE B
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3868
Practice Address - Country:US
Practice Address - Phone:505-243-7655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-04
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1837261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM09555374Medicaid