Provider Demographics
NPI:1255309274
Name:GOTTHEIMER, REBECCA J (RDH)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:J
Last Name:GOTTHEIMER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 MDG
Mailing Address - Street 2:2050A SECOND STREET SE
Mailing Address - City:KIRTLAND AFB
Mailing Address - State:NM
Mailing Address - Zip Code:87117-5522
Mailing Address - Country:US
Mailing Address - Phone:505-853-7857
Mailing Address - Fax:
Practice Address - Street 1:377 MDG
Practice Address - Street 2:2050A SECOND STREET SE
Practice Address - City:KIRTLAND AFB
Practice Address - State:NM
Practice Address - Zip Code:87117-5522
Practice Address - Country:US
Practice Address - Phone:505-853-7857
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNMDH1175124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist