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General NPI Number Information
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NPI Number | 1609176965
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Entity Type | Organization
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Legal Business Name | JUST CLEAN SMILES, LLC
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Dates
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Enumeration Date | 11/02/2010
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Last Update Date | 03/27/2011
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Provider Practice Location Address
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Address Line | 1204 MAIN ST NE SUITE B
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City | LOS LUNAS
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State | NM
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Zip | 87031-7409
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Country | US
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Telephone | 505-565-0609
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Fax | 505-565-0709
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Provider Business Mailing Address
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Address Line | 1204 MAIN ST NE SUITE B
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City | LOS LUNAS
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State | NM
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Zip | 87031-7409
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Country | US
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Telephone | 505-565-0609
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Fax | 505-565-0709
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Authorized Official
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Title or Position | MANAGER/DENTAL HYGIENIST
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Name | DONNA M RIORDAN
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Credential | RDH
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Telephone | 505-565-0609
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 1503
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | DH-373
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License Number State | NM
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