Healthcare Provider Details

I. General information

NPI: 1972303741
Provider Name (Legal Business Name): JENNIFER GOMEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2025
Last Update Date: 03/19/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 LA JOYA ST STE B
ESPANOLA NM
87532-3467
US

IV. Provider business mailing address

538 N PASEO DE ONATE
ESPANOLA NM
87532-2618
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-9454
  • Fax:
Mailing address:
  • Phone: 505-753-7218
  • Fax: 505-747-7396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDB-2025-0016
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: