Provider Demographics
NPI:1215290390
Name:RAWSON, AUDREY MAE N (DDS)
Entity type:Individual
Prefix:DR
First Name:AUDREY MAE
Middle Name:N
Last Name:RAWSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4620 JEFFERSON LN NE STE C
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-2149
Mailing Address - Country:US
Mailing Address - Phone:505-888-3520
Mailing Address - Fax:
Practice Address - Street 1:4620 JEFFERSON LN NE STE C
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2149
Practice Address - Country:US
Practice Address - Phone:505-888-3520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-22
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD52461223P0221X
HI2646122300000X, 1223P0221X
HIDT-26461223P0221X
NMDD44041223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty