Healthcare Provider Details

I. General information

NPI: 1740145879
Provider Name (Legal Business Name): HOLLI MICHELLE PEREA RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2025
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SUDDERTH DR STE C
RUIDOSO NM
88345-5908
US

IV. Provider business mailing address

200 SUDDERTH DR STE C
RUIDOSO NM
88345-5908
US

V. Phone/Fax

Practice location:
  • Phone: 575-286-4321
  • Fax: 575-286-4321
Mailing address:
  • Phone: 575-286-4321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH5253
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: