Healthcare Provider Details

I. General information

NPI: 1801074257
Provider Name (Legal Business Name): JUST FOR GRINS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 02/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1498 S SAINT FRANCIS DR
SANTA FE NM
87505-4038
US

IV. Provider business mailing address

490B W ZIA RD
SANTA FE NM
87505-7008
US

V. Phone/Fax

Practice location:
  • Phone: 505-428-7878
  • Fax:
Mailing address:
  • Phone: 505-428-7878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDD2707
License Number StateNM

VIII. Authorized Official

Name: ELIZABETH PRISHKULNIK
Title or Position: OWNER
Credential: DDS
Phone: 505-428-7878