Healthcare Provider Details

I. General information

NPI: 1467811844
Provider Name (Legal Business Name): STEPHEN MICHAEL VAUGHAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2016
Last Update Date: 02/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 SOUTHERN BLVD SE STE 133
RIO RANCHO NM
87124-3754
US

IV. Provider business mailing address

2003 SOUTHERN BLVD SE STE 133
RIO RANCHO NM
87124-3754
US

V. Phone/Fax

Practice location:
  • Phone: 505-221-5740
  • Fax:
Mailing address:
  • Phone: 505-221-5740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD4769
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: