Healthcare Provider Details

I. General information

NPI: 1255916102
Provider Name (Legal Business Name): J&J DENTISTRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2021
Last Update Date: 03/12/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 CATRON ST
SANTA FE NM
87501-1806
US

IV. Provider business mailing address

312 CATRON ST
SANTA FE NM
87501-1806
US

V. Phone/Fax

Practice location:
  • Phone: 505-986-0606
  • Fax:
Mailing address:
  • Phone: 505-986-0606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JESSICA MERVAU
Title or Position: DENTIST/CEO
Credential:
Phone: 269-908-1589