Healthcare Provider Details

I. General information

NPI: 1780776690
Provider Name (Legal Business Name): GARY ALLEN DOM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 JUAN TABO NE SUITE E
ALBUQUERQUE NM
87112
US

IV. Provider business mailing address

37A MOONLIGHT MEADOW
EDGEWOOD NM
87015
US

V. Phone/Fax

Practice location:
  • Phone: 505-291-8017
  • Fax:
Mailing address:
  • Phone: 505-286-2728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number350
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: