Provider Demographics
NPI:1952642647
Name:DAWES, TERDELL MYCHAL
Entity Type:Individual
Prefix:
First Name:TERDELL
Middle Name:MYCHAL
Last Name:DAWES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 74
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAELS
Mailing Address - State:AZ
Mailing Address - Zip Code:86511-0074
Mailing Address - Country:US
Mailing Address - Phone:928-729-2130
Mailing Address - Fax:928-729-5475
Practice Address - Street 1:PIGEON SPRINGS NHA HOUSING 062
Practice Address - Street 2:
Practice Address - City:FORT DEFIANCE
Practice Address - State:AZ
Practice Address - Zip Code:86504
Practice Address - Country:US
Practice Address - Phone:928-729-2130
Practice Address - Fax:928-729-5475
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle