Healthcare Provider Details

I. General information

NPI: 1821066317
Provider Name (Legal Business Name): SHIRLEY ANN FITE RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 04/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 GRANDE BLVD SE SUITE A
RIO RANCHO NM
87124-1695
US

IV. Provider business mailing address

2200 GRANDE BLVD SE SUITE A
RIO RANCHO NM
87124-1695
US

V. Phone/Fax

Practice location:
  • Phone: 505-891-1500
  • Fax: 505-891-8400
Mailing address:
  • Phone: 505-891-1500
  • Fax: 505-891-8400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH1218
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: