MEDICARE: DR. CLARENCE R REHORN DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DD828	NM

General Provider Information

NPI Number	:	1265653919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CLARENCE R REHORN DDS

Provider Business Mailing Address
First Line	:	2905 RODEO PARK DR E BLDG 4
Second Line	:	STE 200
City	:	SANTA FE
State	:	NM
Zip	:	87505-6313
Country	:	US
Telephone Number	:	505-982-2578
Fax Number	:	505-986-1249

Provider Business Practice Location Address
First Line	:	2905 RODEO PARK DR E BLDG 4
Second Line	:	STE 200
City	:	SANTA FE
State	:	NM
Zip	:	87505-6313
Country	:	US
Telephone Number	:	505-982-2578
Fax Number	:	505-986-1249

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	07/08/2007

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