Healthcare Provider Details

I. General information

NPI: 1164049607
Provider Name (Legal Business Name): FAHIMEH SANATI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2020
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 MAIN ST NW STE D
LOS LUNAS NM
87031-4891
US

IV. Provider business mailing address

2050 E ALGONQUIN RD STE 610
SCHAUMBURG IL
60173-4166
US

V. Phone/Fax

Practice location:
  • Phone: 888-988-4066
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD5286
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: