Provider Demographics
NPI:1558558684
Name:DISHONGH, MARY LINDGREN (DOM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LINDGREN
Last Name:DISHONGH
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:GINGER
Other - Middle Name:
Other - Last Name:DISHONGH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DOM
Mailing Address - Street 1:801 ENCINO PL NE
Mailing Address - Street 2:SUITE B-3
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2612
Mailing Address - Country:US
Mailing Address - Phone:505-688-1118
Mailing Address - Fax:
Practice Address - Street 1:801 ENCINO PL NE
Practice Address - Street 2:SUITE B-3
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2612
Practice Address - Country:US
Practice Address - Phone:505-688-1118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM658171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist