Provider Demographics
NPI:1760929525
Name:PATRICK, TERRY SUSETTE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:TERRY
Middle Name:SUSETTE
Last Name:PATRICK
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 1:5264 10TH ARMORED LOOP
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:31905-7077
Mailing Address - Country:US
Mailing Address - Phone:773-209-4832
Mailing Address - Fax:
Practice Address - Street 1:199 8TH DIVISION RD.
Practice Address - Street 2:SALOMON DENTAL CLINIC
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-7077
Practice Address - Country:US
Practice Address - Phone:706-617-6851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020.010280124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist