Healthcare Provider Details

I. General information

NPI: 1396508255
Provider Name (Legal Business Name): SATIVA MARIE RIDSDALE RDH BS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2024
Last Update Date: 02/02/2024
Certification Date: 02/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 COORS BLVD NW STE A
ALBUQUERQUE NM
87121-1426
US

IV. Provider business mailing address

3808 PUENTA ALTO AVE NE
RIO RANCHO NM
87124-4747
US

V. Phone/Fax

Practice location:
  • Phone: 505-208-0505
  • Fax:
Mailing address:
  • Phone: 505-264-4263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH3039
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: