Provider Demographics
NPI:1245624030
Name:MATA, SELENE (RDH)
Entity type:Individual
Prefix:
First Name:SELENE
Middle Name:
Last Name:MATA
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:PO BOX 13725
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88013-3725
Mailing Address - Country:US
Mailing Address - Phone:575-532-1933
Mailing Address - Fax:
Practice Address - Street 1:385 CALLE DE ALEGRA
Practice Address - Street 2:BUILDING C
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-3423
Practice Address - Country:US
Practice Address - Phone:575-532-1933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-19
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3683124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist