MEDICARE: MRS. LAURA C CHUMLEY RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	10220	TN

General Provider Information

NPI Number	:	1457130353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURA C CHUMLEY RDH

Provider Business Mailing Address
First Line	:	1010 CHERRY BLOSSOM LN
Second Line	:
City	:	CLARKSVILLE
State	:	TN
Zip	:	37040-6426
Country	:	US
Telephone Number	:	931-572-8871
Fax Number	:

Provider Business Practice Location Address
First Line	:	5580 DESERT STORM AVE
Second Line	:
City	:	FORT CAMPBELL
State	:	KY
Zip	:	42223-5586
Country	:	US
Telephone Number	:	270-798-6362
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2023
Last Update Date	:	09/28/2023

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