Provider Demographics
NPI:1982944245
Name:SANDI'S SMILES FOR MILES
Entity Type:Organization
Organization Name:SANDI'S SMILES FOR MILES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:GANSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:NDO-RDH
Authorized Official - Phone:505-480-7200
Mailing Address - Street 1:8408 RANCHO VECINO CT NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-5812
Mailing Address - Country:US
Mailing Address - Phone:505-480-7200
Mailing Address - Fax:
Practice Address - Street 1:901 RIO GRANDE BLVD NW
Practice Address - Street 2:154 G
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104-2057
Practice Address - Country:US
Practice Address - Phone:505-480-7200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-25
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH3281302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization