Healthcare Provider Details

I. General information

NPI: 1982944245
Provider Name (Legal Business Name): SANDI'S SMILES FOR MILES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2013
Last Update Date: 02/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 RIO GRANDE BLVD NW 154 G
ALBUQUERQUE NM
87104-2057
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 Code302F00000X
TaxonomyExclusive Provider Organization
License NumberDH3281
License Number StateNM

VIII. Authorized Official

Name: MRS. SANDRA JEAN GANSHAW
Title or Position: OWNER
Credential: NDO-RDH
Phone: 505-480-7200