Healthcare Provider Details

I. General information

NPI: 1548009111
Provider Name (Legal Business Name): GABRIELLA JAQUEZ RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 S RICHARDS AVE
SANTA FE NM
87508-4887
US

IV. Provider business mailing address

78 NASH ST
RIO COMMUNITIES NM
87002-6022
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-4425
  • Fax:
Mailing address:
  • Phone: 505-507-3149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDB-2024-0127
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: