Provider Demographics
NPI:1609176965
Name:JUST CLEAN SMILES, LLC
Entity Type:Organization
Organization Name:JUST CLEAN SMILES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/DENTAL HYGIENIST
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:RIORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:505-565-0609
Mailing Address - Street 1:1204 MAIN ST NE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-7409
Mailing Address - Country:US
Mailing Address - Phone:505-565-0609
Mailing Address - Fax:505-565-0709
Practice Address - Street 1:1204 MAIN ST NE
Practice Address - Street 2:SUITE B
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-7409
Practice Address - Country:US
Practice Address - Phone:505-565-0609
Practice Address - Fax:505-565-0709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-02
Last Update Date:2011-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1503122300000X
NMDH-373124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty