Healthcare Provider Details

I. General information

NPI: 1740660836
Provider Name (Legal Business Name): TERAH CLIFFORD RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2015
Last Update Date: 04/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 W DL INGRAM BLVD BLDG 1408 DENTAL CLINIC
CANNON AFB NM
88103
US

IV. Provider business mailing address

224 W DL INGRAM BLVD BLDG 1408 DENTAL CLINIC
CANNON AFB NM
88103
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number9550
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: