Provider Demographics
NPI:1396031506
Name:CHURCH, TODD DOUGLAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:DOUGLAS
Last Name:CHURCH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RAF LAKENHEATH 48 MDG/SGHC
Mailing Address - Street 2:UNIT 5115
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09461-5115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:338 S DAKOTA AVE
Practice Address - Street 2:
Practice Address - City:VANDENBERG AFB
Practice Address - State:CA
Practice Address - Zip Code:93437-6307
Practice Address - Country:US
Practice Address - Phone:805-606-1846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-26
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8010086-99221223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist