Healthcare Provider Details

I. General information

NPI: 1295080661
Provider Name (Legal Business Name): NM SMILES GO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2012
Last Update Date: 07/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8604 MESA TOP RD NW
ALBUQUERQUE NM
87120-4310
US

IV. Provider business mailing address

8604 MESA TOP RD NW
ALBUQUERQUE NM
87120-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-836-7337
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2266
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number1503
License Number StateNM

VIII. Authorized Official

Name: MS. GALE JANCSICS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 505-836-7337