Healthcare Provider Details

I. General information

NPI: 1215290390
Provider Name (Legal Business Name): AUDREY MAE N RAWSON D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4620 JEFFERSON LN NE STE C
ALBUQUERQUE NM
87109-2149
US

IV. Provider business mailing address

4620 JEFFERSON LN NE STE C
ALBUQUERQUE NM
87109-2149
US

V. Phone/Fax

Practice location:
  • Phone: 505-888-3520
  • Fax:
Mailing address:
  • Phone: 505-888-3520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDD5246
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2646
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDT-2646
License Number StateHI
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDD4404
License Number StateNM
# 5
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2646
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: