Provider Demographics
NPI:1225257504
Name:CORDOVA, KATHLEEN JOYCE (DDS)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:JOYCE
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15156
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88004-5156
Mailing Address - Country:US
Mailing Address - Phone:505-522-1314
Mailing Address - Fax:
Practice Address - Street 1:1425 S TELSHOR BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-4755
Practice Address - Country:US
Practice Address - Phone:505-522-1314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM14771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice