Healthcare Provider Details

I. General information

NPI: 1194515817
Provider Name (Legal Business Name): MATEUSZ KOLODZIEJCZYK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2025
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12080 LB LINDBECK RD
RADIUM SPRINGS NM
88054
US

IV. Provider business mailing address

PO BOX 370
HATCH NM
87937-0370
US

V. Phone/Fax

Practice location:
  • Phone: 575-526-6200
  • Fax: 575-526-2266
Mailing address:
  • Phone: 575-267-3280
  • Fax: 575-267-1747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDB-2026-0109
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: