Provider Demographics
NPI:1376866988
Name:TERRY, DOMINIQUE LATASHA (RDH)
Entity Type:Individual
Prefix:MRS
First Name:DOMINIQUE
Middle Name:LATASHA
Last Name:TERRY
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 1:2877 POPLAR AVENUE
Mailing Address - Street 2:CHRIST COMMUNITY HEALTH SERVICES INC
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111
Mailing Address - Country:US
Mailing Address - Phone:901-324-0093
Mailing Address - Fax:901-324-4029
Practice Address - Street 1:2595 CENTRAL AVENUE
Practice Address - Street 2:CHRIST COMMUNITY HEALTH SERVICES INC
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104
Practice Address - Country:US
Practice Address - Phone:901-260-8551
Practice Address - Fax:901-260-8590
Is Sole Proprietor?:No
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDH05369124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist