Provider Demographics
NPI:1063921757
Name:DALSIN, MARY KYUNG JIN (LMT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KYUNG JIN
Last Name:DALSIN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 RIO VISTA PL
Mailing Address - Street 2:103
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1563
Mailing Address - Country:US
Mailing Address - Phone:505-629-9498
Mailing Address - Fax:
Practice Address - Street 1:2019 GALISTEO ST STE H2
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2106
Practice Address - Country:US
Practice Address - Phone:505-557-6140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-25
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM8657225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist