Healthcare Provider Details

I. General information

NPI: 1205450939
Provider Name (Legal Business Name): AISLINN B GROVER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2020
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

INDIAN SERVICE RTE 140 & INDIAN SERVICE ROUTE 125
PINEHILL NM
87357
US

IV. Provider business mailing address

PO BOX 496
BLUEWATER NM
87005-0496
US

V. Phone/Fax

Practice location:
  • Phone: 505-806-0025
  • Fax:
Mailing address:
  • Phone: 575-915-5369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH3598
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: