Provider Demographics
NPI:1295222560
Name:WILLOW SPRINGS DENTAL HYGIENE CLINIC
Entity Type:Organization
Organization Name:WILLOW SPRINGS DENTAL HYGIENE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MONTOYA
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:505-280-0876
Mailing Address - Street 1:985 PLAYER LOOP SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-5802
Mailing Address - Country:US
Mailing Address - Phone:505-280-0876
Mailing Address - Fax:
Practice Address - Street 1:1594 SARA RD SE STE C
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1860
Practice Address - Country:US
Practice Address - Phone:505-280-0876
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-21
Last Update Date:2018-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH1332124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty