Provider Demographics
NPI:1396508255
Name:RIDSDALE, SATIVA MARIE (RDH BS)
Entity type:Individual
Prefix:MS
First Name:SATIVA
Middle Name:MARIE
Last Name:RIDSDALE
Suffix:
Gender:F
Credentials:RDH BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3808 PUENTA ALTO AVE NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-4747
Mailing Address - Country:US
Mailing Address - Phone:505-264-4263
Mailing Address - Fax:
Practice Address - Street 1:475 COORS BLVD NW STE A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87121-1426
Practice Address - Country:US
Practice Address - Phone:505-208-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH3039124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist