Provider Demographics
NPI:1205948734
Name:MACKIW, STEPHEN R (DDS, PC)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:R
Last Name:MACKIW
Suffix:
Gender:M
Credentials:DDS, PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 EUBANK BLVD NE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3465
Mailing Address - Country:US
Mailing Address - Phone:505-298-6732
Mailing Address - Fax:505-275-9976
Practice Address - Street 1:3900 EUBANK BLVD NE
Practice Address - Street 2:SUITE 4
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3465
Practice Address - Country:US
Practice Address - Phone:505-298-6732
Practice Address - Fax:505-275-9976
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD24761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice