Provider Demographics
NPI:1225252653
Name:KING-HAMM, TERRILL J (RDH)
Entity Type:Individual
Prefix:MRS
First Name:TERRILL
Middle Name:J
Last Name:KING-HAMM
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 1:652 TERRACE DRIVE
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81503
Mailing Address - Country:US
Mailing Address - Phone:970-261-6535
Mailing Address - Fax:
Practice Address - Street 1:652 TERRACE DR
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81503-8723
Practice Address - Country:US
Practice Address - Phone:970-261-6535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO904083174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CONOT SUREMedicaid