Healthcare Provider Details

I. General information

NPI: 1164529277
Provider Name (Legal Business Name): THERESA BROWN-DOONQUAH DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 WEST HIGHWAY 22 KEWA PUEBLO HEALTH CORPORATION
SANTO DOMINGO PUEBLO NM
87052-0340
US

IV. Provider business mailing address

PO BOX 340 KEWA PUEBLO HEALTH CORPORATION
SANTO DOMINGO PUEBLO NM
87052-0340
US

V. Phone/Fax

Practice location:
  • Phone: 505-465-3078
  • Fax: 505-465-1153
Mailing address:
  • Phone: 505-465-3078
  • Fax: 505-465-1153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401008335
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: