Provider Demographics
NPI:1588131908
Name:MARES, DUSTIE JO
Entity type:Individual
Prefix:
First Name:DUSTIE
Middle Name:JO
Last Name:MARES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4934
Mailing Address - Country:US
Mailing Address - Phone:505-903-3892
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:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM8840225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist