Healthcare Provider Details

I. General information

NPI: 1609176965
Provider Name (Legal Business Name): JUST CLEAN SMILES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2010
Last Update Date: 03/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 MAIN ST NE SUITE B
LOS LUNAS NM
87031-7409
US

IV. Provider business mailing address

1204 MAIN ST NE SUITE B
LOS LUNAS NM
87031-7409
US

V. Phone/Fax

Practice location:
  • Phone: 505-565-0609
  • Fax: 505-565-0709
Mailing address:
  • Phone: 505-565-0609
  • Fax: 505-565-0709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number1503
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH-373
License Number StateNM

VIII. Authorized Official

Name: DONNA M RIORDAN
Title or Position: MANAGER/DENTAL HYGIENIST
Credential: RDH
Phone: 505-565-0609