Provider Demographics
NPI:1750559639
Name:TERRY, LORI MARISA (RDHAP)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:MARISA
Last Name:TERRY
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:MRS
Other - First Name:LORETTA
Other - Middle Name:MARISA
Other - Last Name:CARELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDHAP
Mailing Address - Street 1:1512 ULLREY AVE
Mailing Address - Street 2:
Mailing Address - City:ESCALON
Mailing Address - State:CA
Mailing Address - Zip Code:95320-9658
Mailing Address - Country:US
Mailing Address - Phone:209-610-0575
Mailing Address - Fax:
Practice Address - Street 1:1512 ULLREY AVE
Practice Address - Street 2:
Practice Address - City:ESCALON
Practice Address - State:CA
Practice Address - Zip Code:95320-9658
Practice Address - Country:US
Practice Address - Phone:209-610-0575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDHAP 203124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist