Healthcare Provider Details

I. General information

NPI: 1306528161
Provider Name (Legal Business Name): AMY KATHRYN GREER RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2023
Last Update Date: 08/02/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 W D.L. INGRAM AVE
CANNON AFB NM
88101
US

IV. Provider business mailing address

25 REPUBLIC CT
CLOVIS NM
88101-8336
US

V. Phone/Fax

Practice location:
  • Phone: 575-784-4041
  • Fax:
Mailing address:
  • Phone: 360-556-8807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH5617
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: