Provider Demographics
NPI:1063929503
Name:MCCAULEY, JO ANN
Entity type:Individual
Prefix:
First Name:JO
Middle Name:ANN
Last Name:MCCAULEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3087
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88221-3087
Mailing Address - Country:US
Mailing Address - Phone:575-236-1001
Mailing Address - Fax:
Practice Address - Street 1:114 W FOX ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-6212
Practice Address - Country:US
Practice Address - Phone:575-236-1001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-05
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH1521124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist