Provider Demographics
NPI:1063632594
Name:KEHOE, DENNIS BERNARD (OD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:BERNARD
Last Name:KEHOE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 WYOMING BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3117
Mailing Address - Country:US
Mailing Address - Phone:505-884-8477
Mailing Address - Fax:505-884-8477
Practice Address - Street 1:4200 WYOMING BLVD NE
Practice Address - Street 2:OPTOMETRIST OFFICE
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3117
Practice Address - Country:US
Practice Address - Phone:505-884-8477
Practice Address - Fax:505-884-8477
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCS00019241152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM07738811Medicare ID - Type UnspecifiedOPTOMETRIST