Healthcare Provider Details

I. General information

NPI: 1104845486
Provider Name (Legal Business Name): MICHAEL STEPHEN DONDELINGER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 LAJOYA ST. SUITE B
ESPANOLA NM
87532
US

IV. Provider business mailing address

1870 BROADVIEW DR
LOS ALAMOS NM
87544-2800
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-9454
  • Fax: 505-753-1212
Mailing address:
  • Phone: 505-662-7405
  • Fax: 505-753-1212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1231
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: