Healthcare Provider Details

I. General information

NPI: 1184219552
Provider Name (Legal Business Name): RHONDA MARIE MCCRORY OROFACIAL MYOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2021
Last Update Date: 03/07/2021
Certification Date: 08/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3323 2ND ST E
WEST FARGO ND
58078-7953
US

IV. Provider business mailing address

3323 2ND ST E
WEST FARGO ND
58078-7953
US

V. Phone/Fax

Practice location:
  • Phone: 701-793-2873
  • Fax:
Mailing address:
  • Phone: 701-515-1876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number635
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: