Healthcare Provider Details

I. General information

NPI: 1205064409
Provider Name (Legal Business Name): RACHEL HARMS FANNING DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2009
Last Update Date: 08/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 GEORGIA ST NE SUITE C4
ALBUQUERQUE NM
87110-1359
US

IV. Provider business mailing address

5507 EAKES RD NW
LOS RANCHOS NM
87107-5529
US

V. Phone/Fax

Practice location:
  • Phone: 505-884-9798
  • Fax:
Mailing address:
  • Phone: 573-230-7237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD3429
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: