Healthcare Provider Details

I. General information

NPI: 1699330969
Provider Name (Legal Business Name): JONATHAN EDWARD PAUWELS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 10/12/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 DON PASQUAL RD NW
LOS LUNAS NM
87031-8841
US

IV. Provider business mailing address

145 DON PASQUAL RD NW
LOS LUNAS NM
87031-8841
US

V. Phone/Fax

Practice location:
  • Phone: 505-865-4618
  • Fax:
Mailing address:
  • Phone: 505-865-4618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD5127
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: