Healthcare Provider Details

I. General information

NPI: 1992091821
Provider Name (Legal Business Name): NM SMILES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 06/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4943 STORY ROCK ST NW
ALBUQUERQUE NM
87120-3703
US

IV. Provider business mailing address

4943 STORY ROCK ST NW
ALBUQUERQUE NM
87120-3703
US

V. Phone/Fax

Practice location:
  • Phone: 505-980-0070
  • Fax:
Mailing address:
  • Phone: 505-980-0070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD1503
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH2266
License Number StateNM

VIII. Authorized Official

Name: GALE E JANCSICS
Title or Position: OWNER
Credential: RDH
Phone: 505-980-0070