Healthcare Provider Details

I. General information

NPI: 1457034738
Provider Name (Legal Business Name): COURTNEY DIANE GRIM RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2023
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4730 BECKNER ROAD
SANTA FE NM
87507
US

IV. Provider business mailing address

4736 SNOWY OWL RD NE
RIO RANCHO NM
87144-7635
US

V. Phone/Fax

Practice location:
  • Phone: 505-989-4500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH4121
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: