Provider Demographics
NPI:1922719590
Name:MYRICK, DENISE LEANN (RDH)
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:LEANN
Last Name:MYRICK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MS
Other - First Name:DENISE
Other - Middle Name:L
Other - Last Name:TEAGUE MYRICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX Z
Mailing Address - Street 2:
Mailing Address - City:JAL
Mailing Address - State:NM
Mailing Address - Zip Code:88252-2525
Mailing Address - Country:US
Mailing Address - Phone:575-395-2205
Mailing Address - Fax:575-395-2209
Practice Address - Street 1:423 S 3RD ST
Practice Address - Street 2:
Practice Address - City:JAL
Practice Address - State:NM
Practice Address - Zip Code:88252-5024
Practice Address - Country:US
Practice Address - Phone:575-395-2205
Practice Address - Fax:575-395-2209
Is Sole Proprietor?:No
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDH2377124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist