Healthcare Provider Details

I. General information

NPI: 1295156370
Provider Name (Legal Business Name): DINA DENISE RODRIGUEZ D.O.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2013
Last Update Date: 11/09/2021
Certification Date: 11/09/2021
Deactivation Date: 09/20/2021
Reactivation Date: 11/09/2021

III. Provider practice location address

5200 EUBANK BLVD NE SUITE C-3
ALBUQUERQUE NM
87111-1759
US

IV. Provider business mailing address

5320 HERITAGE WAY NE APT. B
ALBUQUERQUE NM
87109-3225
US

V. Phone/Fax

Practice location:
  • Phone: 505-323-8100
  • Fax: 505-292-0555
Mailing address:
  • Phone: 805-233-4998
  • Fax: 505-292-0555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number1130
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: