Healthcare Provider Details

I. General information

NPI: 1356940787
Provider Name (Legal Business Name): CARRIE BOEHM RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2020
Last Update Date: 10/16/2020
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2844 E MAIN ST STE 106-145
FARMINGTON NM
87402-5260
US

IV. Provider business mailing address

2844 E MAIN ST STE 106-145
FARMINGTON NM
87402-5260
US

V. Phone/Fax

Practice location:
  • Phone: 505-360-0024
  • Fax:
Mailing address:
  • Phone: 505-360-0024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: