Provider Demographics
NPI:1194834242
Name:BERRY, KATHERINE E (RDH)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:E
Last Name:BERRY
Suffix:
Gender:F
Credentials:RDH
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 220
Mailing Address - Street 2:
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528-0220
Mailing Address - Country:US
Mailing Address - Phone:575-759-0062
Mailing Address - Fax:
Practice Address - Street 1:12000 STONE LAKE RD
Practice Address - Street 2:JICARILLA APACHE HEALTH CARE FACILITY, IHS
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528-0000
Practice Address - Country:US
Practice Address - Phone:575-759-3291
Practice Address - Fax:575-759-3651
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY532124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMHSZ196OtherMEDICARE PART B
NM000K3526Medicaid
NM000K3526Medicaid