Provider Demographics
NPI:1962965665
Name:CLOUGH, RICHARD HAYES JR (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:HAYES
Last Name:CLOUGH
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 AMSTERDAM AVE APT 2B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-3974
Mailing Address - Country:US
Mailing Address - Phone:360-393-9526
Mailing Address - Fax:
Practice Address - Street 1:224 36TH ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-6540
Practice Address - Country:US
Practice Address - Phone:360-255-0553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61074242122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADE61074242OtherWASHINGTON STATE DEPARTMENT OF HEALTH