Healthcare Provider Details

I. General information

NPI: 1548483688
Provider Name (Legal Business Name): KATHLEEN J MATHEWS DOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 GOLD AVE SW SUITE 1060
ALBUQUERQUE NM
87102-3283
US

IV. Provider business mailing address

400 GOLD AVE SW SUITE 1060
ALBUQUERQUE NM
87102-3283
US

V. Phone/Fax

Practice location:
  • Phone: 505-848-7828
  • Fax:
Mailing address:
  • Phone: 505-848-7828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number835
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: