Organization
NIRVANA LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. JULIE RAYE FULLER RDH (CO-OWNER)
(505) 553-6850
Entity
Organization
Contact information
Practice address
161 RAILCAR RD, CORRALES, NM 87048-7909
(505) 553-6850
Mailing address
161 RAILCAR RD, CORRALES, NM 87048-7909
(505) 553-6850
Taxonomy
Speciality
Code
Description
License number
State
124Q00000X
Dental Hygienist
DH1235
NM
124Q00000X
Dental Hygienist
Primary
DH986
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
65028066
—
NM
Enumeration date
09/26/2008
Last updated
09/26/2008
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