Provider Demographics
NPI:1740286780
Name:DORNER, DENISE M (DPM)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:M
Last Name:DORNER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4801 N BUTLER AVE STE 14-102
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-0815
Mailing Address - Country:US
Mailing Address - Phone:505-327-3650
Mailing Address - Fax:505-327-2350
Practice Address - Street 1:4801 N BUTLER AVE
Practice Address - Street 2:STE 14102
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-6002
Practice Address - Country:US
Practice Address - Phone:505-327-3650
Practice Address - Fax:505-327-2350
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPOD213213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM59931Medicaid
NMF8031Medicaid