Provider Demographics
NPI:1790568558
Name:WIDENER, MICHAEL DALE (DN)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DALE
Last Name:WIDENER
Suffix:
Gender:M
Credentials:DN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 EL PASO RD
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-6033
Mailing Address - Country:US
Mailing Address - Phone:575-973-1514
Mailing Address - Fax:
Practice Address - Street 1:103 EL PASO RD
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6033
Practice Address - Country:US
Practice Address - Phone:575-973-1514
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1029172P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172P00000XOther Service ProvidersNaprapath