=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962965665
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD HAYES CLOUGH JR. DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2019
-----------------------------------------------------
Last Update Date | 11/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 224 36TH ST
-----------------------------------------------------
City | BELLINGHAM
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98225-6540
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-255-0553
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 906 AMSTERDAM AVE APT 2B
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10025-3974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-393-9526
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 61074242
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------