Healthcare Provider Details

I. General information

NPI: 1578822607
Provider Name (Legal Business Name): SANDRA JEAN GANSHAW RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2012
Last Update Date: 05/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 SAN FELIPE ST NW
ALBUQUERQUE NM
87104-1370
US

IV. Provider business mailing address

8408 RANCHO VECINO CT NW
ALBUQUERQUE NM
87120-5812
US

V. Phone/Fax

Practice location:
  • Phone: 505-480-7200
  • Fax:
Mailing address:
  • Phone: 505-480-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH 3281
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberNDO0007
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: