Provider Demographics
NPI:1104114164
Name:GALLEGOS, PHILIP M (DDS)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:M
Last Name:GALLEGOS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 JEFFERSON ST NE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3489
Mailing Address - Country:US
Mailing Address - Phone:505-298-7475
Mailing Address - Fax:505-323-0997
Practice Address - Street 1:6500 JEFFERSON ST NE
Practice Address - Street 2:SUITE 250
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3489
Practice Address - Country:US
Practice Address - Phone:505-298-7475
Practice Address - Fax:505-323-0997
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2011-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM34931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice