Healthcare Provider Details

I. General information

NPI: 1235594292
Provider Name (Legal Business Name): ANDREA ROSE PHILLIPS RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2015
Last Update Date: 09/22/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JUNCTION RD 371 RT 9
CROWNPOINT NM
87313
US

IV. Provider business mailing address

JUNCTION RD 371 RT 9 PO BOX 358
CROWNPOINT NM
87313
US

V. Phone/Fax

Practice location:
  • Phone: 505-786-6283
  • Fax:
Mailing address:
  • Phone: 505-786-6283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH9313
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: