Healthcare Provider Details

I. General information

NPI: 1629355441
Provider Name (Legal Business Name): JANA CRUICKSHANK RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2011
Last Update Date: 11/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 CAMINO DE SALUD NORTH EAST
ALBUQUERQUE NM
87102
US

IV. Provider business mailing address

1801 CAMINO DE SALUD NORTH EAST
ALBUQUERQUE NM
87102
US

V. Phone/Fax

Practice location:
  • Phone: 505-925-7767
  • Fax:
Mailing address:
  • Phone: 505-925-7767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH3559
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: