Provider Demographics
NPI:1033621503
Name:DERK, CARRIE MICHELE (RDH, PHDHP)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:MICHELE
Last Name:DERK
Suffix:
Gender:F
Credentials:RDH, PHDHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:767 5TH AVE STE B-3A
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-4207
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:767 5TH AVE STE B-3A
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17201-4207
Practice Address - Country:US
Practice Address - Phone:717-709-7940
Practice Address - Fax:717-263-8014
Is Sole Proprietor?:No
Enumeration Date:2017-10-24
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPHDH000337124Q00000X
PADH068197124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist