Healthcare Provider Details

I. General information

NPI: 1790964633
Provider Name (Legal Business Name): DAWEI SHAO DOM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2007
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 GEORGIA ST NE STE C2
ALBUQUERQUE NM
87110
US

IV. Provider business mailing address

6709 TESOSO PL NE
ALBUQUERQUE NM
87113
US

V. Phone/Fax

Practice location:
  • Phone: 505-918-7075
  • Fax: 505-221-5157
Mailing address:
  • Phone: 505-918-7075
  • Fax: 505-221-5157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number951
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: